Ep 164 Cardiogenic Shock Simplified

In this Part 2 of our 2-part podcast series on acute heart failure we dive into the diagnosis and management of the patient in cardiogenic shock and wrap up with some guidance to disposition decisions of the patient with acute heart failure in general. Thankfully, only about 10% of our heart failure patients will be in cardiogenic shock, but this a very challenging subgroup of patients with a high mortality rate of 30% that we need to be comfortable treating. With the help of Dr. Tarlan Hedayati and Dr. Bourke Tillmann we answer questions such as: what is the preferred order of vasopressors and ionotropes in the management of cardiogenic shock? In which patients would dobutamine be preferred over milrinone and vice versa? How can we best pick up occult cardiogenic shock before it floured shock kicks in? What are the best strategies to efficiently get the patient in cardiogenic shock to definitive care, whether that be the cath lab or the operating room? What is the evidence for intra-aortic balloon pumps, percutaneous ventricular assist devices and ECMO in the patient with cardiogenic shock? Which patients with acute heart are safe to send home in general? How useful is the Ottawa Heart Failure Risk Score in aiding in disposition decisions? and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Saswata Deb, edited by Anton Helman January 2022 Cite this podcast as: Helman, A. Hedayati, T, Tillmann, B. Cardiogenic Shock. Emergency Medicine Cases. January, 2022. https://emergencymedicinecases.com/cardiogenic-shock. Accessed [date] Go to part 1 of this 2-part podcast on acute heart failure Understanding the reduced contractility and assessment of end-organ perfusion is key to managing patients with cardiogenic shock Reduced contractility is the keystone of cardiogenic shock Cardiogenic shock is defined as systolic blood pressure (SBP) < 90mmHg or the need for pharmacological or mechanical support to maintain a SBP > 90mmHg and evidence of end-organ perfusion. Chronic heart failure progresses into cardiogenic shock when the reduced contractility of the ventricle impairs mean arterial pressures and cardiac output which results in decreased end-organ perfusion. Assessment of end-organ perfusion is central to identifying occult cardiogenic shock  Patients with heart failure may have a lower baseline SBP due to heart-failure related pharmacotherapy which can make the diagnosis of cardiogenic shock difficult. A "soft" SBP may be the patients baseline or it may represent occult shock. Assessing for impaired end-organ perfusion in these patients can significantly aid in the identification of occult cardiogenic shock. On the other hand, a patient can be in a pre-cardiogenic shock, hypertensive state such as SCAPE (see Part 1). Again, assessment for impaired end-organ perfusion can be very helpful in diagnosis and management. Assessment of end-organ perfusion involves assessment of the skin, mental status, urine output and PoCUS parameters. Assess the skin for 1. mottling 2. cool temperature 3. prolonged capillary refill time. Altered mental status and oliguria/anuria are often present. An elevated lactate is suggestive or poor end-organ perfusion although the specificity is poor. Advanced doppler PoCUS may aid in assessment of end organ perfusion (portal vein pulsatility index, renal doppler resistive index, splenic doppler resistive index). A central venous-arterial gap >6mmHg is an indicator of decreased systemic...