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Shelley Hart Alverno College- MSN 621 [email protected] 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: 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 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 Would you like to learn more about the physiology of the heart? Sheffield, 2008 Click here for a heart link : http://www.getbodysmart.com/ap/circulator ysystem/heart/menu/menu.html 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 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 Adapted from: ER Club of NYU School of Medicine,2007. Abnormal Q wave -No depolarizing -necrotic /damaged heart tissue -change in conduction 1 mm 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 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 Cool Right Answer Move on to Compensation Microsoftclipart,2008 These are important tests but would NOT be urgent for a cardiac problem ,go back please… 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 Rethink this.. This test takes a long time to peak in the blood, a cardiac problem is urgent ,need information in minutes Microsoftclipart.com2008 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? SNS RAA Inflammatory Compensatory Mechanisms Microsoftclipart.com,2008 Kidney 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. Renin BP Blood Pressure 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 First the blood pressure falls Second, Renin is released from the kidneys ReninThird reactsstep with the protein, Angiotensinogen th step 4Angiotensin I is formed Angiotensin Converting Enzyme (ACE) from the lungs converts… Angiotensin II is a product of the Next? conversion and causes… Vasoconstriction, Result Move on to see how aldosterone impacts this picture Microsoftclipart.com,2008 Aldosterone flips on the switch for the sodium and potassium pump. •Angiotensin II stimulates the release of aldosterone from the adrenal cortex Aldosterone is released Na+/ K+ Pump switch is ON •Kidneys conserve sodium •Kidneys conserve water •Thus the blood pressure increases Blood volume increases Then what happens? SNS causes vasoconstriction Then the heart rate increases The heart contraction is stronger BUT in this situation the heart is weakened from the cardiac event The ventricles cannot pump effectively and overfill with blood Alpha receptors are on blood vessels ,skin and eyes and start to affect their normal function AND Beta adrenergic receptors start to affect the heart , lungs, and other tissues Alpha and beta adrenergic receptors Body Microsoftclipart,2008 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 eyes heart Blood vessel Microsoftclipart,2008 lungs 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 Hooray you are correct!! Move on to inflammation Close but this is incorrect The lungs do host the angiotensin converting enzyme but does not secrete renin No…. this answer is incorrect The brain is not involved directly with renin secretion Choose another answer The heart does not secrete renin Living cells in the tissue are injured without oxygen This cardiac event is preventing oxygen from getting to the tissues Cytokines are released Leukocytes are alerted !! Alert Injury !! Sheffield,2008 Cytokines are released!! 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 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 Leukocytes make integrins Integrins help leukocytes bind to the endothelium Leukocytes Action 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 Endothelium Action 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 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 Leukocytes Platelets Interstitial leakage Sticky endothelium and pooling of blood products 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 Try again Your answer is part of the inflammatory response but it’s earlier in the events of the total result to the body Hooray your answer is correct !!! Move on to patient care 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 What will you see, hear and feel from the patient? Chest Pain Suggests a myocardial infarct 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 Microsoftclipart,2008 Assessment 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 Signs and symptoms Microsoftclipart,2008 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 Excellent you are right !! Move on to lab values No try again… These are signs and symptoms but there are two issues that this patient complains of pinpoint cardiac problems This isn’t exactly correct…. Chest pain is the main cardinal sign of a cardiac problem and this patient also exhibited something else Elevated myocardial tissue markers ◦ Elevated myocardial bands of creatinine phophokinase( MK-CPK) ◦ Elevated Troponin I ◦ Elevated BNP-Brain Natriuretic Peptide Arterial Blood Gases ◦ Decreased PaO2 C Reactive Protein Hemodynamic values Lab Values Microsoftclipart,2008 Assessment Narcotics IV fluids Arterial Line Central Line Electrolyte replacement ECG, Cardiac monitor ◦ K+, Calcium, Mg+ ◦ Cardioversion ◦ Pacing Possible Diuretics Antidysrhythmic drugs Vasodilators Narcotics Procedures What will the physician order? Microsoftclipart,2008 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) 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 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 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 Let’s try to see the whole picture using the nursing process… 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.. Problem 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 What you know so far… Microsoft clipart,2008 Medical Procedures for Monitoring Purposes The cardiologist placed an Intra arterial balloon pump for increased myocardial perfusion. He also placed pulmonary arterial catheter and arterial line. Chester has a foley catheter in place Monitor for changes in ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Level of consciousness Heart rate Blood pressure ( Low B/P can lead to further organ damage) SpO2 Breath sounds Urine output Pain and anxiety Microsoft clipart,2008 Monitoring Equipment Administer medications ◦ Adjust per lab and monitor interpretation • Diuretics • Vasopressors ( lo B/P) Is there fluid overload ? Should I adjust the IV fluids? Dobutamine, S>80 Dopamine , S<80 Norepinephrine • Vasodilators Nitroglycerin Oxygenation ◦ Possible monitor of mechanical ventilation Assessment Intervention and Evaluation Microsoftclipart,2008 Critical Thinking Assess fluid overload by labs and these signs and symptoms: ◦ Frothy secretions ◦ Decreased oxygen saturation ◦ Crackles Values that are important: ◦ Decreased B/P ◦ Narrow pulse pressure ◦ Cardiac index < 2.1 l/min/m2 ◦ Pulmonary artery wedge pressure > 20mmHG ( normal is 8-12 mmHg) ◦ Central venous pressure ( normal is 2-6 mm Hg.) He is somewhat short of breath, mild chest pain and anxious about surgery. His lung sounds reveal slight crackles in the bases His wedge pressure is 22, CVP is 12 and his urine output is still low ASSESS You reassure the patient that his family is aware of the situation . The cardiac team is here and he is going in for surgery in 15 min. You start a dobutamine drip at 5 mcg/min/kg IV and dopamine 5 mcg/min/kg IV. Plus he still on a heparin drip. You give him 1 mg morphine IV for pain and anxiety. Interpret and Intervene The cardiac team arrives You give report that Chester is less anxious,pain free at this time He still has increased urine output but it is still low. You have not increased his amount of fluid per hour. He still has crackles in his lungs Evaluation Further labs are drawn and the cardiac enzymes are still elevated, the BUN and creat are elevated You send Chester off to the operating room where he has a successful by pass of 4 arteries. You later learn that he went home 5 days later. Further treatment Monitoring and correcting low blood pressure with vasopressors is important to : A) prevent organ damage B) Keep patients comfortable C) correct breathing problems D) increase the oxygenation Fluid overload may be characterized by: A) pain B) decreased blood pressure, low urine output C) Lung assessment that includes crackles, low B/P ,low urine output D) hypertension with wide pulse pressure Last slide Celebrate !! This is a good answer. All of the organs have to function for the best patient outcome. Incorrect Breathing will not improve from vasopressors. The action of the medication will increase the blood pressure and return oxygen perfusion to the tissues Pick another answer… Oxygenation may improve from better tissue perfusion to the organs so this isn’t the total outcome Go back and try again Pain is not affected by vasopressors or increasing the blood pressure Great !! You need assessment skills plus the medical information to intervene properly Last slide Sorry Not the answer The blood pressure and urine output may be a problem of a result of organ damage or increased heart damage Sorry Not the answer Pain is indicative of an advancing cardiac event Sorry Not the answer Hypertension and wide pulse pressure is the opposite of what the body would do during fluid overload in this case You are finished!! Microsoftclipart.com2008 Appolini, O., Dupont, E., Vandercruys, M., Andrien, M., Duchateau, J., & Vincent, J. (2004). Association between the TNF-2 Allele and a Better Survival in Cardiogenic shock . Chest, 125(6), 2232-2237. Brandler, E., & Sinert, R. (2008, Apr. 2). eMedicine - Shock, Cardiogenic : Article by Ethan S Brandler. Retrieved Apr. 14, 2008, from http://www.emedicine.com/emerg Feldman, H., & Rey, M. (n.d.). Learning EKG interpretation. Retrieved Apr. 11, 2008, from students.med.nyu.edu/erclub/ekghome.html. Morton, P., Fontaine, D., Hudak, C., & Gallo, B. (2005). Critical Care Nursing : A holistic approach, 8th edition. Philadelphia, PA: Lippincott,Williams & Wilkins. Mower -Wade, D., Bartley, M., & Chiari-Allwein, J. (2000). Shock Do you know how to respond?. Nursing 2000, 30(10), 34-39. Sheffield, S. (2008, Apr. 14). GetBodySmart: Interactive Tutorials and Quizzes On Human Anatomy and Physiology. Retrieved Apr. 14, 2008, from http://www.getbodysmart.com. Weil, M. (n.d.). Shock: Shock and fluid resuscitation: Merck Manual Professional . Retrieved Apr. 14, 2008, from http://www.merck.com/mmpe/print/sec06/ch067/ch067b.html.