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Jun 19, 2023 14 tweets 5 min read Read on X
Randomised clinical trials in cardiogenic shock in the PCI era Image
Treatment considerations for patients with AMI-cardiogenic shock Image
Enrolment data for major randomised cardiogenic shock trials (EuroIntervention 2021; 17: 451-65) ImageImage
Determination of the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage using the revised SCAI Shock Classification Image
Conceptual model showing the overlap between
different states of hemodynamic compromise. Shock is defined by presence of hypoperfusion; most, but NOT ALL, patients will also be hypotensive. Pts w hemodynamic instability who do not meet criteria for shock are labeled as pre-shock Image
Management algorithm for patients with or at risk for cardiogenic shock (CS) tailored to the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage Image
Framework of clinical parameters to follow in patients with heart failure-related cardiogenic shock in the critical care unit Image
Considerations for invasive hemodynamic assessment in HF-CS Image
Classification and management of HF-CS Image
It seems that the most controversial issue is the use of short-term mechanical circulatory support for cardiogenic shock. So, a very recent publication deals with this: Image
Proposed overview of selection of patients to pVAD based on SCAI shock class A-E Image
Flowchart to identify and handle potential need for escalation of mechanical circulatory support in patients supported by axial flow pump (AFP) Image
Flowchart to identify and handle potential need for venting during V-A ECMO support Image

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More from @IM_Crit_

Nov 29
ICU Stories:

Middle-aged pt w many co-morbidities (CAD/DM2/strokes/seizures/peripheral vasc dz/a.fibrillation/chronic Foley - UTIs etc) was sent from nursing home to the ED for evaluation of fever/hypotension. Urine was purulent. CT A/P: hydronephrosis & bladder wall thickening: Image
Image
Patient received "sepsis fluid bolus" & antibiotics (meropenem* & vanco); admitted to the hospitalists' service. Urine & blood cultures grew E .coli. Next day, pt was transferred to the ICU with altered mental status & oral bleeding secondary to tongue biting after a seizure
Review of admission labs: WBC 15k, Hb 10.6, PLT 120k, bun/creat 100/3.0 (baseline 15/10.7)
Home meds: apixaban/aspirin/divalproex sodium/escitalopram/folic acid/insulin/ hydrochlorothiazide/empagliflozin/statin/clopidogrel /quetiapine
Read 17 tweets
Nov 24
ICU Hemodynamics:

What changed in this case between a and b? Image
What changed in this case (different from the previous) between c and d? Image
Pulsus bisferiens is a 2-peak waveform during systole seen in severe aortic regurg & hypertrophic obstructive cardiomyopathy. The early wave component is attributed to rapid LV ejection; the late component is due to the back pressure exerted by the recoil of arterial musculature
Read 5 tweets
Nov 17
Very nice overview of the current state of affairs in cardiogenic shock (published this week in @TheLancet): Image
Classification systems and key risk factors for cardiogenic shock: Image
Summary of main causes and pathophysiological mechanisms of cardiogenic shock: Image
Read 13 tweets
Oct 30
Mixed cardiogenic shock (CS) -herein classified as CS with at least 1 additional contributing cause of shock state- is common (& usually quite challenging to treat...)

20% of all shock patients admitted to contemporary cardiac ICUs have mixed CS

Besides this old-school approach Image
It's good to keep in mind the proposed "normal" hemodynamic compensation & criteria for mixed cardiac-vasodilatory shock: Image
Simplified approach to identifying mixed shock states in patients presenting with primary cardiogenic or vasodilatory shock in the cardiac ICU using invasive hemodynamic parameters: Image
Read 5 tweets
Oct 28
ICU/ED ECG Secrets:

New fear unlocked:

40 yo male, previously healthy, referred to the ED post-CPR after documented ventricular fibrillation
(VF). Vitals & physical exam: OK. No family history of sudden death. No drugs.

Any concern from this 12-lead electrocardiogram (ECG)? Image
What do you think the most likely concern/explanation is?
ECG shows sinus rhythm with prominent J waves in leads II, III, and aVF and V4 through V6. The height of the J wave was > 0.2mV (> 0.3mV in leads II, III, and aVF). The slope of the ST segment was horizontal in lead II and down-sloping in leads III and aVF Image
Image
Read 8 tweets
Oct 26
ICU (Central Venous/Arterial) Line Secrets - Part 3:

Following from where I stopped last week & if you are not already bored by parts 1 & 2, there are some additional points that may be worth noting

Here the (probably) final part begins:
41. If you think that the patient will need dialysis or right heart catheterization in the next few hours, consider placing a dialysis catheter or an introducer sheath from the beginning
42. Classical teaching is that we should never lose sight of the back end of the wire when advancing it. But - trust me - this complication still happens even in the best hospitals. Before calling Vascular or Radiology, you may still have a chance to save the day: get an x-ray &
Read 22 tweets

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