WHAT WENT WRONG?
A drop in
blood pressure and blood flow caused by the heart’s inability to pump
blood as a
result of a cardiac emergency, such as cardiac tamponade, myocardial
ischemia,
myocarditis, or cardiomyopathy (a disease of the heart that deteriorates
the heart
muscle). Blood pools in the left ventricle, which causes a back up of blood
into the
lungs, resulting in pulmonary edema. Contractions increase to compensate
for the
decreased cardiac output, causing an increase in demand for oxygen by
the heart.
However, the lungs are not oxygenating the blood sufficiently due to
decreased
blood flow; and therefore heart muscles are starved for oxygen.
PROGNOSIS
Treatment
needs to find a balance between improving cardiac output and reducing
oxygen needs
and cardiac workload of the myocardium. This balance must be
achieved while
maintaining perfusion of the heart muscle. Prognosis depends on
finding and
treating the underlying cause. Cardiogenic shock requires immediate
treatment,
often before the cause is known.
HALLMARK SIGNS AND
SYMPTOMS
• Hypotension,
because blood flow decreases below normal.
• Tachycardia,
because the heart is trying to pump faster to maintain adequate
blood flow to
the body, or occasionally bradycardia, where the heart rate is
less than 60
beats per minute due to myocardial damage.
• Arrhythmias—when
the heart muscle does not have enough oxygen it
becomes
irritable, making arrhythmias more likely.
• Clammy
skin, because oxygenation to tissues is reduced.
• Drop
in skin temperature because of reduced circulation as a result of
hypotension.
• Urine
output less than 30 ml per hour (oliguria) because the kidneys are not
being
perfused.
• Crackles
heard in the lungs secondary to pulmonary edema, meaning fluidis
building up in
lungs.
• Confusion
due to poor perfusion.
• Distended
jugular veins—sign of fluid overload, inability of heart to manage
fluid coming
into heart.
• Cyanosis
of lips, peripheral extremities due to poor perfusion.
INTERPRETING TEST RESULTS
• Chemistry—check
electrolytes, kidney function to ascertain kidney perfusion;
calcium level
is increased or decreased secondary to muscle contractility.
• Echocardiogram—to
look for ventricular rupture, pericarditis, or valve dysfunction.
• Electrocardiogram:
• Q-wave
enlarged due to heart failure.
• Elevation
of ST-waves is a sign of ischemia.
TREATMENT
Treatment is
based on medical support for the heart until etiology (cause) can be
determined. In
cardiogenic stroke, the stroke volume and the heart rate must be increased
to keep the
organs perfused. The effects of the following medications should
accomplish this.
• Administer
vasodilator—dilates blood vessels (arterial and venous) to decrease
the venous
return to the heart and reduces the peripheral arterial resistance
(what the
heart has to pump against).
• Nitroprusside;
nitroglycerin.
• Administer
adrenergic agent—to increase the heart rate and blood pressure:
• epinephrine.
• Administer
inotropes strengthens the heart beat, improves contractions, produces
peripheral
vasoconstriction:
• dopamine
• dobutamine
• inammone
• milrinone
• Administer
vasopressor decreases blood flow to all organs except the heart
and brain:
• norepinephrine
• Provide
supplemental oxygen—may need to be via intubation.
DIAGNOSES
• Ineffective
tissue perfusion
• Decreased
cardiac output
INTERVENTION
• Monitor
vital signs—look for changes in BP, P, R.
• Monitor
heart sounds.
• Monitor
Swanz Ganz catheter is a catheter placed into the pulmonary artery
to check for
pressures in the heart, vessels, and lungs.
• Test
capillary refill.
• Monitor
arterial blood gas to learn pH, acidosis or alkalosis, bicarb level.
• Monitor
respiratory status—due to poor perfusion, these patients are in respiratory
distress;
mechanical ventilation may be needed.
• Place
the patient on bed rest.
• Monitor intake and
output of fluids—look for adequate renal perfusion.
Without
sufficient cardiac function, the patient will not have enough blood
flow to the
kidneys to get adequate filtration.
• Explain
to the patient:
• Which
symptoms to be aware of and when to call the doctor.
• Take
rest periods.
• Call
the physician if there are signs of fluid overload—weight increase,
shortness of
breath, fatigue, dependent edema.
• Record
weight each day and call the physician, nurse practitioner, or
physician
assistant if there is an increase of 3 lbs (1.4 kg).
• Change
to a low-sodium, low-fat diet.
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