Randomised clinical trials in cardiogenic shock in the PCI era
Treatment considerations for patients with AMI-cardiogenic shock
Enrolment data for major randomised cardiogenic shock trials (EuroIntervention 2021; 17: 451-65)
Determination of the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage using the revised SCAI Shock Classification
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
Management algorithm for patients with or at risk for cardiogenic shock (CS) tailored to the Society for Cardiovascular Angiography and Intervention (SCAI) Shock stage
Framework of clinical parameters to follow in patients with heart failure-related cardiogenic shock in the critical care unit
Considerations for invasive hemodynamic assessment in HF-CS
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:
Proposed overview of selection of patients to pVAD based on SCAI shock class A-E
Flowchart to identify and handle potential need for escalation of mechanical circulatory support in patients supported by axial flow pump (AFP)
Flowchart to identify and handle potential need for venting during V-A ECMO support
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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:
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
What changed in this case (different from the previous) between c and d?
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
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
It's good to keep in mind the proposed "normal" hemodynamic compensation & criteria for mixed cardiac-vasodilatory shock:
Simplified approach to identifying mixed shock states in patients presenting with primary cardiogenic or vasodilatory shock in the cardiac ICU using invasive hemodynamic parameters:
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)?
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
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 &