Cardiogenic Shock
Patient Presentation:
T.G., an overweight 65 year old female was a Rapid Response. On arrival to the patient’s room she was diaphoretic, complaining of jaw pain, short of breath requiring supplemental oxygen, tachycardic into the 110s, and she was screaming, “I am going to die!” An EKG was quickly done which showed ST segment elevation in leads V2, V3, and V4. A “Cath Attack” was called, defib pads were placed on her and pt was given a chewable ASA, 4mg of morphine, 0.3 mg NTG SL every five minutes for three doses. Pt continued to experience severe chest pain and quickly deteriorated to a Code Blue. Initial rhythm on monitor was ventricular fibrillation and pt was immediately shocked and CPR was in progress, including intubation. Pt received several rounds of epinephrine, atropine, vasopressin, and sodium bicarb, and was shocked three more times before the cardiac cath team arrived. Pt has a known history of ETOH, 30 pack year h/o smoking, type 2 diabetes, HLD, and CRI.
Differential List:
Cardiogenic shock
STEMI
Pulmonary Embolism
Myocardial Rupture
Additional tests & Diagnosis:
WBC: 16.33, Hgb: 7.9, Hct: 24, Platelets 89, D-dimer 3.23
pH: 7.12, HCO3: 18, PaCO2: 55, PaO2: 68, base excess: -13, Lactate: 18, SvO2: 38%
Na+: 138, K+: 2.3, BUN: 48, Creatinine: 1.8, Magnesium: 1.1
VS ICU: BP 78/34, RR 24 (vent), HR 121, Sinus tachycardia with multifocal PVCs.
Cardiac Catheterization: 90% occlusion to the proximal LAD and 100% to the distal LAD. Ejection fraction 10%. Stroke Volume 30, Cardiac Output 3.6 L/min with a cardiac index of 1.3 L/min, PAWP 20, and PAP elevated.
Diagnosis: STEMI induced Cardiogenic Shock
Treatment:
Pt V-fib arrested on the cath table and was coded again for 20 minutes. Pt received two stents to the proximal LAD and distal LAD. IABP inserted into the right femoral artery. Swan Ganz catheter inserted via right femoral vein. Pt required massive doses of epinephrine, Levophed®, vasopressin, and dopamine on continuous intravenous gtt to sustain MAP >55 and try to increase CI > 2.2, as ordered. 2 L 0.9% saline boluses given, Bicarb gtt started along with 3 amps IV push. Serial ABGs with lactate levels were ordered q 2 hrs, Swann Ganz catheter monitoring hourly. IABP ordered to continue on 1:1.
Outcome:
Pt subsequently coded the next day after admittance to the ICU. Unfortunately, she did not survive the code.
Case created by Theresa Ganoe, 2010.