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Ix and Mx of MI and cardiogenic shock (Presentation (Investigations (Needs…
Ix and Mx of MI and cardiogenic shock
Definition - Persistent hypotension (MAP 30 lower baseline) with severe reduction in cardiac index (<1.8 without support or <2.2 with) persistent for at least 30mins which is secondary to cardiac dysfunction
Aetiology
Causes
LV dysfunction (75%) - usually LV infarction
Ventricular septal rupture (5%)
Acute MR (8%)
Isolated RV dysfunction (3%)
Cardiac tamponade or rupture (1%)
Pathophysiology
Muscle hypoxia = necrosis = compromised contractility = decreased cardiac output
SNS and RAAS activation = vasoconstriction = further compromise coronary
Lactate and acidosis further compromise contractility until BP unable to sustain life
Presentation
Background
Cardiac RFs e.g. diabetes, smoking, male, older
Median time from infarction to shock 5-6 hrs
Symptoms
Those of AMI - chest pain, dyspnoea, sweating etc.
Those of shock - altered mental state
Signs
Hypotension, tachycardia, periph vasocon (slow cap refill, faint pulse), cyanosis, Left heart signs (APO, pulm congestion), Right heart signs - global (JVP raised), new murmur, decreased urine output, unresponsive to fluid, responds to inotropes
Investigations
Needs rapid diagnosis and institution of therapy
ECG - STEMI (most common)/NSTEMI/Arrhythmia
Exclusion of other causes (Hb, CRP/WCC)
ABG - acidosis, lactate
Cardiac enzymes
Coagulation profile if DIC
ECHO - evidence myocardial dysfunction, valves, walls, tamponade, exclude PE, aortic dissection
Right heart catheterisation (controversial) - CI low, increased pulm wedge pressure (>15mmHg)
Investigate other conditions which may complicate cardiogenic shock - haemorrhage, bowel ischaemia etc.