Cardiogenic Shock : Can You Keep the Beat ?

1. Cardiogenic Shock : Can You Keep the Beat ? Shelley Hart Alverno College- MSN 621 harts63@yahoo.com

2. Welcome The following information will lead you through this self paced learning activity • Click on any underlined words for an in depth explanation • Use the arrows at the bottom of the page to move around the tutorial • Use this arrow to move forward: • Use this arrow to move backward: • Use this button to return to the beginning of the show:

3. Objectives After this tutorial you will be able to : 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

4. What does cardiogenic shock mean? • 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 Sheffield, 2008 Would you like to learn more about the physiology of the heart? Click here for a heart link : http://www.getbodysmart.com/ap/circulatorysystem/heart/menu/menu.html

5. Myocardial Injury • Why? • Impaired blood flow to the coronary arteries • 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 • When can you diagnose this problem ? • Timing of serum cardiac marker elevation Porth,2005,p.539

6. ECG changes and Heart injury 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 Abnormal Q wave -No depolarizing -necrotic /damaged heart tissue -change in conduction 1 mm Adapted from: ER Club of NYU School of Medicine,2007.

7. Serum cardiac markers • 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: • Myoglobin- within 1 hour • Creatine-kinase MB ( CK-MB)- within 4-8 Hours • Troponin I- within 3 hours • Troponin T- within 3 hours

8. Time to check on learning • 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 • 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

9. Cool Right Answer Move on to Compensation Microsoftclipart,2008

10. These are important tests but would NOT be urgent for a cardiac problem ,go back please…

11. 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

12. Rethink this.. This test takes a long time to peak in the blood, a cardiac problem is urgent ,need information in minutes Microsoftclipart.com2008

13. Compensation and Low Oxygen • 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? Compensatory Mechanisms

14. A small organ with a big function • 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. Microsoftclipart.com,2008 Kidney

15. Small organ with major functions • 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 Renin BP Blood Pressure

16. ReninAngiotensinAldosterone First the blood pressure falls Third step 4th step Next? Result Second, Renin is released from the kidneys Renin reacts with the protein, Angiotensinogen Angiotensin I is formed Angiotensin Converting Enzyme (ACE) from the lungs converts… Angiotensin II is a product of the conversion and causes… Vasoconstriction, Move on to see how aldosterone impacts this picture Microsoftclipart.com,2008

17. What about aldosterone? Aldosterone flips on the switch for the sodium and potassium pump.

18. SNS: Sympathetic Nervous SystemAgain…triggered by low blood pressure from the weak and poorly contracting heart Then what happens?

19. SNS: Norepinephrine and epinephrine released and causes increased vasoconstriction and excites various bodily organs and function Alpha and beta adrenergic receptors Body Microsoftclipart,2008

20. How does your body start to respond to the myocardial injury for survival? eyes • 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 heart lungs Blood vessel Microsoftclipart,2008

21. Time to review: • What organ is involved with renin secretion? • A. heart • B. lungs • C. kidney • D. brain • 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

22. Hooray you are correct!! Move on to inflammation

23. Close but this is incorrect The lungs do host the angiotensin converting enzyme but does not secrete renin

24. No…. this answer is incorrect The brain is not involved directly with renin secretion

25. Choose another answer The heart does not secrete renin

26. Tissue injury triggers the inflammatory process • Living cells in the tissue are injured without oxygen • This cardiac event is preventing oxygen from getting to the tissues • Cytokines are released Alert Injury !! Sheffield,2008 Leukocytes are alerted !! Cytokines are released!!

27. Cytokines • 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

28. Can genetics play a role in the survival of cardiogenic shock? How does Tumor necrosis factor fit into this picture? • 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

29. Leukocytes “stop” and attach to the endothelium • Leukocytes make integrins • Integrins help leukocytes bind to the endothelium • 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 Leukocytes Action Endothelium Action

30. Action in the Inflammatory response 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

31. Vasodilation is an outcome of inflammation • 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 Platelets Leukocytes Interstitial leakage Sticky endothelium and pooling of blood products

32. Inflammation Review: • 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

33. Try again Your answer is part of the inflammatory response but it’s earlier in the events of the total result to the body

34. Hooray your answer is correct !!! Move on to patient care

35. Patient Care: Risk Factors Who is at risk for cardiogenic shock? • Patient 65 years or older • High blood pressure • Diabetes • Obesity • Those who smoke • Hyperdyslipidemia • Frequency • 8.6% of patients with a ST elevation MI Microsoftclipart,2008 May develop hours after the initial MI is detected

36. What will you see, hear and feel from the patient? Chest Pain Suggests a myocardial infarct

37. What else will you see, hear and feel from the patient? • 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 Assessment Microsoftclipart,2008

38. Decreased Cardiac Output • Produce these signs and symptoms: • Rapid pulse • Narrow pulse pressure • Distended neck veins • Right ventricular failure • Arrhythmias • Decreased mentation • Dyspnea • Elevated respiratory rate • Inspiratory crackles, wheezing • Left ventricular failure • Absent bowel sounds Microsoftclipart,2008 Signs and symptoms

39. Signs and Symptoms Review • 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. • 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

40. Excellent you are right !! Move on to lab values

41. No try again… These are signs and symptoms but there are two issues that this patient complains of pinpoint cardiac problems

42. This isn’t exactly correct…. Chest pain is the main cardinal sign of a cardiac problem and this patient also exhibited something else

43. What will the lab values reveal? • Elevated myocardial tissue markers • Elevated myocardial bands of creatininephophokinase( MK-CPK) • Elevated Troponin I • Elevated BNP-Brain Natriuretic Peptide • Arterial Blood Gases • Decreased PaO2 • C Reactive Protein • Hemodynamic values Microsoftclipart,2008 Lab Values Assessment

44. Management • Narcotics • IV fluids • Arterial Line • Central Line • Electrolyte replacement • K+, Calcium, Mg+ • ECG, Cardiac monitor • Cardioversion • Pacing • Possible Diuretics • Antidysrhythmic drugs • Vasodilators • Narcotics • Procedures Microsoftclipart,2008 What will the physician order?

45. Medical Procedures • 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)

46. Case Study: How would you respond ? • 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… • What will you expect the physician to order immediately: • A) Blood cultures • B) ECG, IV fluids, Oxygen support • C ) Antihistamine • D) Abdominal x- rays Go to next case study

47. 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

48. 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

49. Case scenario Let’s try to see the whole picture using the nursing process…

50. Patient scenario: Chester Pain Patient • 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.. • 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 Problem What you know so far…