Transcript Cardiogenic Shock: can you keep the beat?

Shelley Hart
Alverno College- MSN 621
[email protected]
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Click on any underlined words for an in depth explanation
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Understand the pathophysiology of cardiogenic shock
Explain the compensatory mechanism for low
oxygenation to the tissues
Identify the what you see as signs and symptoms of
cardiogenic shock
Identify the nursing interventions for the assessment
and management of cardiogenic shock
Usually there is a
myocardial injury and a
loss of contractility of
the heart
Then the heart is
unable to provide
enough oxygen to the
body resulting in poor
tissue perfusion to the
major organs
Would you like to learn more about
the physiology of the heart?
Sheffield, 2008
Click here for a heart link
:
http://www.getbodysmart.com/ap/circulator
ysystem/heart/menu/menu.html
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Why?
◦ Impaired blood flow to the coronary arteries
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How does this look?
◦ Blood flow is blocked either by a clot or plaque in
various degrees, so part of the artery is blocked or
most of it is blocked
◦ ECG will show changes T wave inversion, ST
segment elevation or abnormal Q wave
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When can you diagnose this problem ?
◦ Timing of serum cardiac marker elevation
Porth,2005,p.539
Normal ECG waveform
ST wave elevation
-First changes seen
-Abrupt onset and chest pain
-Signal that heart muscle is damaged
T –wave inversion
-disruption in repolarization
-may be earliest sign of Myocardial injury
Q wave ST
T wave
Adapted from:
ER Club of NYU School of Medicine,2007.
Abnormal Q wave
-No depolarizing
-necrotic /damaged heart
tissue
-change in conduction
1 mm
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Enzymes within the markers located in the
heart muscle breakdown and are released
during heart damage
They are seen in blood within certain times frames of a heart
attack or also called MI:
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Myoglobin- within 1 hour
Creatine-kinase MB ( CK-MB)- within 4-8 Hours
Troponin I- within 3 hours
Troponin T- within 3 hours
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If a patient enters
with chest pain and
ECG changes that
show a ST elevation.
You may need to
review lab results
called…
A) coag panel
B) serum cardiac
markers
C) UA and culture
D) CBC with diff
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The earliest blood
test that may show
cardiac damage
would be
A) troponin I
B) troponin T
C) myoglobin
D) CK- MB
Let’s move on to compensation
Cool Right Answer
Move on to Compensation
Microsoftclipart,2008
These are important tests but would NOT be
urgent for a cardiac problem ,go back please…
Think cardiac to cardiac enzymes..go back
Chest pain indicates a cardiac problem rather than a clotting problem. A coag
panel determines a clotting time
Microsoftclipart.com2008
Rethink this..
This test takes a long time to peak in the blood, a cardiac problem is urgent
,need information in minutes
Microsoftclipart.com2008
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OK we know the cause of
the problem now to the
next part of the
problem..
In the beginning of
shock, the tissues are not
receiving enough oxygen
because there is less
blood flow to the organs
How does the body try to
restore blood flow to the
major organs?
SNS
RAA
Inflammatory
Compensatory
Mechanisms
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Microsoftclipart.com,2008
Kidney
The kidney plays a big
role in the function of
the blood pressure
Special enzymes are
secreted to help the
blood pressure from
going too high or too
low. This is important
in cardiogenic shock.
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Renin
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BP
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Blood Pressure
Remember the heart is not
pumping normally, so the
blood vessels are not
working properly and the
blood pressure decreases .
An enzyme called Renin is
secreted from the kidney
Renin secretion sets a
pathway into motion
Vasoconstriction is a result
of this pathway
And Vasoconstriction
causes a slight rise in the
blood pressure
First the blood pressure falls
Second, Renin is released
from the kidneys
ReninThird
reactsstep
with the protein, Angiotensinogen
th step
4Angiotensin
I is formed
Angiotensin Converting
Enzyme (ACE) from the
lungs converts…
Angiotensin II is a product of the
Next?
conversion and causes…
Vasoconstriction,
Result
Move on to see how aldosterone impacts this picture
Microsoftclipart.com,2008
Aldosterone flips on the switch for the sodium
and potassium pump.
•Angiotensin II
stimulates the
release of
aldosterone from
the adrenal
cortex
Aldosterone is
released
Na+/ K+ Pump
switch is ON
•Kidneys conserve
sodium
•Kidneys conserve
water
•Thus the blood
pressure
increases
Blood volume
increases
Then what happens?
SNS causes vasoconstriction
Then the heart rate increases
The heart contraction is stronger
BUT in this situation the heart is
weakened from the cardiac event
The ventricles cannot pump
effectively and overfill with blood
Alpha receptors
are on blood
vessels ,skin and
eyes and start to
affect their normal
function AND
Beta adrenergic
receptors start
to affect the
heart , lungs,
and other
tissues
Alpha and beta
adrenergic receptors
Body
Microsoftclipart,2008
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Where are the alpha and
beta receptors that cause
vasoconstriction and
cause excitation?
Click on alpha or beta to
match the affected organ
alpha
alpha
beta
beta
eyes
heart
Blood vessel
Microsoftclipart,2008
lungs
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What organ is
involved with renin
secretion?
A. heart
B. lungs
C. kidney
D. brain
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The body
compensates for
decreased tissue
perfusion by :
A. Decreasing the
heart rate
B. Vasoconstriction
C. Vasodilation
D. Decreasing the
blood pressure
Move on to inflammation
Hooray you are correct!!
Move on to inflammation
Close but this is incorrect
The lungs do host the angiotensin converting enzyme
but does not secrete renin
No…. this answer is incorrect
The brain is not involved directly with renin secretion
Choose another answer
The heart does not secrete renin
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Living cells in the
tissue are injured
without oxygen
This cardiac event is
preventing oxygen
from getting to the
tissues
Cytokines are released
Leukocytes are alerted !!
Alert
Injury !!
Sheffield,2008
Cytokines are released!!
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A cytokine is an
inflammatory mediator
that communicates with
other cells important to
the inflammatory
response
Some bind to the cell
surface receptors and
trigger release of more
cytokines and nitric
oxide (NO)
Nitric oxide is a strong
vasodilator
Attention all neutrophils,
I need assistance at this
point of injury !
Microsoftclipart,2008
Cytokine
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Tumor Necrosis Factor ( TNF)
is an inflammatory mediator
and one of the cytokines in
the inflammatory process
People that have a genetic
TNF-2 allele, may survive
cardiogenic shock at a better
rate than patients without the
allele or people with TNF 1
allele
Interestingly enough the
opposite has been observed
in patients with septic shock
Microsoftclipart,2008
TNF
Genetic connection in
survival
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Leukocytes make
integrins
Integrins help
leukocytes bind to the
endothelium
Leukocytes Action
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Just as leukocytes are
making integrins
The endothelium is
making integrin
receptors and selectins
The cytokines will
activate the integrins
to attach to the
receptors
Endothelium Action
The endothelium has the
leukocytes sticking to
it
Cytokines are releasing
nitric oxide causing
vasodilation
What is happening?
Picture the cytokine action
and leukocyte effect
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Pooling of blood and slowing
of blood flow through the
capillaries
Increased permeability and
leaking of fluid into interstitial
space
Platelets and leukocytes stick
and clog up the endothelial
wall
Leukocytes
Platelets
Interstitial leakage
Sticky endothelium and
pooling of blood products
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The end result of the
inflammatory
response in
cardiogenic shock is:
A) leaky vessels
B) decreased oxygen
to the major organs
C) Cytokine secretion
D) Endothelium
Changes
www.getbodysmart.com,2008
Try again
Your answer is part of the inflammatory response but it’s earlier in the
events of the total result to the body
Hooray your answer is correct !!!
Move on to patient care
Who is at risk for
cardiogenic shock?
 Patient 65 years or
older
 High blood pressure
 Diabetes
 Obesity
 Those who smoke
 Hyperdyslipidemia
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Frequency
◦ 8.6% of patients with a ST
elevation MI
Microsoftclipart,2008
May develop hours after
the initial MI is detected
What will you see, hear and feel from
the patient?
Chest
Pain
Suggests a myocardial infarct
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Minimally you will see:
◦ Cool extremities
◦ Decreased urine
output
◦ And most
importantly a low
blood pressure
with systolic <90
mmHg
Microsoftclipart.com,2008
Defining symptoms
Microsoftclipart,2008
Assessment
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Produce these signs and
symptoms:
◦ Rapid pulse
◦ Narrow pulse pressure
◦ Distended neck veins
 Right ventricular failure
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Arrhythmias
Decreased mentation
Dyspnea
Elevated respiratory rate
Inspiratory crackles, wheezing
 Left ventricular failure
◦ Absent bowel sounds
Signs and symptoms
Microsoftclipart,2008
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Mr. CP is a 55 year old
man that enters the
emergency room
complaining of
cramping abdominal
pain and chest
pressure as well as
nausea. He is cool and
clammy to the touch.
He states he cannot
remember his phone
number and he feels
scared about this
feeling of pain in
chest.
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The main defining
symptoms of a cardiac
injury and possibly
cardiogenic shock
would include:
A) chest pain
B) chest pain, cool and
clammy skin
C) confusion
D) chest pain and
confusion
Move on to lab values
Excellent you are right !!
Move on to lab values
No try again…
These are signs and symptoms but there are two issues that this patient
complains of pinpoint cardiac problems
This isn’t exactly correct….
Chest pain is the main cardinal sign of a cardiac problem and this patient also
exhibited something else
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Elevated myocardial
tissue markers
◦ Elevated myocardial bands
of creatinine
phophokinase( MK-CPK)
◦ Elevated Troponin I
◦ Elevated BNP-Brain
Natriuretic Peptide
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Arterial Blood Gases
◦ Decreased PaO2
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C Reactive Protein
Hemodynamic values
Lab Values
Microsoftclipart,2008
Assessment
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Narcotics
IV fluids
Arterial Line
Central Line
Electrolyte replacement
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ECG, Cardiac monitor
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◦ K+, Calcium, Mg+
◦ Cardioversion
◦ Pacing
Possible Diuretics
Antidysrhythmic drugs
Vasodilators
Narcotics
Procedures
What will the physician
order?
Microsoftclipart,2008
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Immediate revascularization is necessary to
restore oxygen to the heart muscle and then
support oxygen delivery to the rest of the
body
Intra-Aortic Balloon Pump (IABP) used as a
bridge until revascular efforts are completed
Coronary Artery Bypass Graft (CABG)
Percutaneous Coronary Intervention (PCI)
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Mr. CP is a 55 year old man
that enters the emergency
room complaining of cramping
abdominal pain and chest
pressure as well as nausea. He
is cool and clammy to the
touch. He states he cannot
remember his phone number
and he feels scared about this
feeling of pain in chest.
You take his vital signs and
determine that his blood
pressure is 80/50 and his
heart rate is 96. While you call
the physician and other staff to
assist you with this patient…
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What will you expect the
physician to order
immediately:
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A) Blood cultures
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B) ECG, IV fluids, Oxygen
support
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C ) Antihistamine
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D) Abdominal x- rays
Go to next case study
Super … right selection
The suspected shock is cardiogenic with the hallmark sign of chest pain, life
saving measures need to start after the initial assessment
Go to next case study
Let’s rethink that response
Unfortunately that is incorrect
Remember that chest pain and symptoms of decreased cardiac output would
need interventions that would increase vasodilation and increase oxygen
Let’s try to see the whole
picture using the nursing
process…
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Chester Pain is your patient
returning from the cardiac
cath lab until the cardiac
surgical team arrives. The
cardiologist noticed several
blockages but he was
unable to advance the guide
wire.
The cardiothoracic team is
coming in to perform an
emergency bypass surgery.
In the meantime..
Problem
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You will need to
monitor and intervene
on the cardiac unit
until the surgical team
arrives…
Chester’s B/P is
80/50, pulse is 115.
He is also diaphoretic,
weak pulses, low urine
output, mild confusion
and some agitation
What you know so far…
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Microsoft clipart,2008
Medical Procedures for
Monitoring Purposes
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The cardiologist placed
an Intra arterial balloon
pump for increased
myocardial perfusion.
He also placed
pulmonary arterial
catheter and arterial
line.
Chester has a foley
catheter in place
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Monitor for changes in
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Level of consciousness
Heart rate
Blood pressure
( Low B/P can lead to
further organ damage)
SpO2
Breath sounds
Urine output
Pain and anxiety
Microsoft clipart,2008
Monitoring
Equipment
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Administer medications
◦ Adjust per lab and monitor
interpretation
• Diuretics
• Vasopressors ( lo B/P)
Is there fluid overload ?
Should I adjust the IV fluids?
Dobutamine, S>80
Dopamine , S<80
Norepinephrine
• Vasodilators
Nitroglycerin
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Oxygenation
◦ Possible monitor of mechanical
ventilation
Assessment
Intervention and Evaluation
Microsoftclipart,2008
Critical Thinking
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Assess fluid overload
by labs and these signs
and symptoms:
◦ Frothy secretions
◦ Decreased oxygen
saturation
◦ Crackles
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Values that are
important:
◦ Decreased B/P
◦ Narrow pulse pressure
◦ Cardiac index < 2.1
l/min/m2
◦ Pulmonary artery wedge
pressure > 20mmHG
( normal is 8-12 mmHg)
◦ Central venous pressure
( normal is 2-6 mm Hg.)
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He is somewhat short
of breath, mild chest
pain and anxious
about surgery.
His lung sounds reveal
slight crackles in the
bases
His wedge pressure is
22, CVP is 12 and his
urine output is still low
ASSESS
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You reassure the patient
that his family is aware
of the situation . The
cardiac team is here and
he is going in for surgery
in 15 min.
You start a dobutamine
drip at 5 mcg/min/kg IV
and dopamine 5
mcg/min/kg IV. Plus he
still on a heparin drip.
You give him 1 mg
morphine IV for pain and
anxiety.
Interpret and Intervene
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The cardiac team arrives
You give report that
Chester is less
anxious,pain free at this
time
He still has increased
urine output but it is still
low. You have not
increased his amount of
fluid per hour.
He still has crackles in
his lungs
Evaluation
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Further labs are drawn
and the cardiac enzymes
are still elevated, the BUN
and creat are elevated
You send Chester off to
the operating room
where he has a
successful by pass of 4
arteries.
You later learn that he
went home 5 days later.
Further treatment
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Monitoring and
correcting low blood
pressure with
vasopressors is
important to :
A) prevent organ
damage
B) Keep patients
comfortable
C) correct breathing
problems
D) increase the
oxygenation
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Fluid overload may
be characterized by:
A) pain
B) decreased blood
pressure, low urine
output
C) Lung assessment
that includes
crackles, low B/P ,low
urine output
D) hypertension with
wide pulse pressure
Last slide
Celebrate !!
This is a good answer. All of the organs have to function for the best patient
outcome.
Incorrect
Breathing will not improve from vasopressors. The action of the medication will
increase the blood pressure and return oxygen perfusion to the tissues
Pick another answer…
Oxygenation may improve from better tissue perfusion to the organs so this
isn’t the total outcome
Go back and try again
Pain is not affected by vasopressors or increasing the blood pressure
Great !!
You need assessment skills plus the medical information to intervene properly
Last slide
Sorry Not the answer
The blood pressure and urine output may be a problem of a result of organ
damage or increased heart damage
Sorry Not the answer
Pain is indicative of an advancing cardiac event
Sorry Not the answer
Hypertension and wide pulse pressure is the opposite of what the body would
do during fluid overload in this case
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You are finished!!
Microsoftclipart.com2008
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Vincent, J. (2004). Association between the TNF-2 Allele and a
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Article by Ethan S Brandler. Retrieved Apr. 14, 2008, from
http://www.emedicine.com/emerg
Feldman, H., & Rey, M. (n.d.). Learning EKG interpretation. Retrieved Apr.
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