Cardiogenic Shock = a cardiac disorder that results in both clinical and biochemical evidence of sustained tissue hypoperfusion (1).
Cardiogenic shock has high mortality (approx 35-40% in many studies). Mortality worsens at higher stages of cardiogenic shock severity (2,3). Early recognition of cardiogenic shock is critical in order to initiate treatment and transfer patients to an appropriate level of care in a timely manner.
As an ED physician, you need to SUSPECT cardiogenic shock so that you can ensure appropriate definitive management of your patient (4).
SUSPECT = Symptoms/Signs; Urine Output; Sustained Hypotension; Perfusion; EKG/Echo; Congestion; Triage
Take a look at the Additional Materials to break down this mnemonic in more detail and learn what might make you SUSPECT CS!
Additional Information
So what do you need to think about to SUSPECT CS?
Let's break down that mnemonic in a little bit more detail.
Symptoms/Signs:
- Signs of Shock (Hypoperfusion): AMS, confusion, rapid pulse, cold and clammy extremities, delayed capillary refill
- Signs of Congestion: Elevated JVP, crackles, rales, lower extremity edema, narrow pulse pressure (<25% of SBP)
- Symptoms: Chest pain or pressure, chest pain equivalents, orthopnea, paroxysmal nocturnal dyspnea
Urine Output:
- Oliguria or anuria
- <0.5 mL/kg/h (roughly <30 mL/h in a 60 kg adult)
- Place a foley (most accurate hourly UOP), or measure UOP into a urinal, bedpan, Purewick, or condom cath
Sustained Hypotension:
- SBP <90, MAP <65 for >30 min
- Or… relative hypotension! >30 mmHg decrease from baseline
- Or… anyone who needs pressors or mechanical support to maintain SBP >90
- Not every patient with cardiogenic shock will have hypotension (yet)!
Perfusion:
- Lactate: >2
- LFTs: ALT >200 U/L or >3x upper limit of normal
- Renal function: AKI, AKI on CKD, or Cr >2x upper limit of normal (very concerning)
- Acidosis: pH <7.2 (very concerning), or metabolic acidosis without another clear etiology
- You don't need all of the above to be concerned for cardiogenic shock
EKG/Echocardiogram:
- EKG: STEMI? Arrhythmias? New conduction abnormalities (AV block, LBBB or RBBB)?
- POCUS: Visually estimate EF, evaluate for LV and/or RV dilation and systolic dysfunction, look for regional wall motion abnormalities
- More detailed echo: assess for valvular pathology, more accurate quantification of EF (LVOT-VTI, Simpson’s Biplane, etc)
Congestion:
- Assess for presence or absence of congestion based on physical exam and hemodynamics
- LV congestion: think about pulmonary edema
- RV congestion: think about extremity edema, cardiac ascites, elevated JVP, hepatic dysfunction
- Biventricular congestion: all of the above!
Triage:
- ICU admission!
- AMI-CS (Acute MI causing cardiogenic shock): activate cath lab
- HF-CS (decompensated heart failure, either acute or chronic, causing cardiogenic shock): call heart failure team (if available at your hospital) to discuss advanced therapeutics
- Choose cardiac ICU if available
- Activate shock team (if available) to discuss advanced therapeutic options
- No shock team? Call your ICU, call your on-call cardiologist, and talk through options!
- Consider transfer to a higher level of care if:
- You don’t have access to a cath lab or advanced level of cardiology services
- You don’t have a cardiac ICU or a MICU with capacity to do advanced hemodynamic monitoring
- Your patient might need mechanical circulatory support
- Your patient might need evaluation for surgical treatment options (CABG, valve repair/replacement, etc)
Proposed Classification of Cardiogenic Shock Levels of Care (originally figure 3, Sinha et al)
Consider the resources that your hospital has available when deciding if/where to transfer a cardiogenic shock patient to a higher level of care.