Don't miss cardiogenic shock in the ED!

High mortality that increases when diagnosis is delayed

Use careful exam, labs, ECG and POCUS to dx

A few tips from our recent paper Madison Daly @long_brit @EMHighAK @UVMEmergencyMed

#foamcc #FOAMed

https://www.ajemjournal.com/article/S0735-6757(20)30839-1/pdf

Avoid the "everything is Sepsis" trap!

Examine for signs of Cardiogenic Cause:

1. Hypoperfusion: cool extremities, AMS, oliguria, etc.

2. Congestion: elevated JVP or JVD, pulmonary edema, etc

3. Vitals: narrow pulse pressure, > 5% may not have hypotension

4. New murmur? S3?

Get an ECG! (MI most common cause)

Labs: Lactate elevation, AKI, troponin, SCVO2 low

POCUS for LVEF (mean 30% EF in CS), IVC, RV function, estimate CO (LVOT VTI), pulm edema (better than CXR)

Stabilize:
Avoid med iatrogenesis (BB, CCB, excess fluids)

No congestion on exam? Consider small (250-500 ml) fluid boluses

Start norepinephrine to MAP ~ >65 (18% have inappropriately low SVR)

Add dobutamine if hypoperfusion still exists

Treat underlying causes MI?-> cath lab

Nice skin mottling images from a very relevant case report of cardiogenic shock in @NEJM

If you see this check the heart!

Skin Mottling | NEJM https://www.nejm.org/doi/full/10.1056/NEJMicm1602055#.X4dXXW8Xncg.twitter