 Welcome to Nursing School Explained and this video on cardiogenic shock. Whenever we talk about the heart's function, we have to refer back to this important formula. Cardiac output equals stroke volume times heart rate. And that really refers back to the pumping ability of the heart. The cardiac output is comprised of the stroke volume, which is the volume of blood that the heart pumps in one minute multiplied by the heart rate, so how many heart beats we have per minute. And the cardiac output is so important because it is what provides the nourishment, the blood, the oxygen to all the tissues in the body, not only the important organs such as the heart, the brain, the kidneys, but also all the digestive organs and every cells of the musculoskeletal system all the way down to the pinky toes. So we really have to always keep this formula in mind. And when we talk about cardiogenic shock, then there's something wrong with the heart's ability to pump or fill. Hence we have causes can be either systolic or diastolic in nature. Recall that systolic function is the ability of the heart to pump. What diastolic function is the passive filling of the heart chambers during the rest period, during the diastolic period. And so when we have pump failure, systolic failure, that is the most common cause is because of myocardial infarction. So there is now part of the heart that has been infarcted or is ischemic and therefore can no longer pump as efficiently. So that heart muscle is not able to pump and produce that cardiac output. But we also mostly think about left sided heart failure when we talk about systolic failure, but it can also be diastolic, meaning right sided heart failure or fill failure. And that is really because once the left ventricle fails, things will start to back up the opposite way of the normal blood flow into the lungs and then therefore the right side of the heart eventually will be affected as well. So pulmonary hypertension, which is a cause that originates in the lungs, can also lead to systolic failure here. And then cardiomyopathy, sure enough when the heart muscle itself is diseased and is not able to contract as efficiently, that can be a cause of cardiogenic shock as well. Now for diastolic fulfilling pressures, cardiac tamponade would be when there is excessive pressure on the outside of the heart itself. So when there's a constriction, the heart can't pump so it can't fill. And then ventricular hypertrophy as discussed as well as cardiomyopathy. But again, the most common cause is because of myocardial infarction. And certainly this rythmias, brady dysrhythmias as well as tacky dysrhythmias can cause cardiogenic shock. So if the heart is beating too fast or too quickly, it can cause trouble that lead to cardiogenic shock. And then structural defects or any kind of valve disorders or congenital heart defects can also lead to congenital to cardiogenic shock. And please know that I have videos on pretty much all of these topics that you have here. So refer back to those to the more detailed pathophysiology. So now when we look at the pathophysiology, so for the systolic pressure now we have problems with the filling ability of the heart. So now that cardiac output is going to be decreased. Sorry, systolic is the pumping ability of the heart. So when the heart can't pump the blood out to the body, that cardiac output is going to be decreased, which also means that the stroke volume is decreased. So less volume is being pumped, which means that there's less O2 to all the cells and the organs of the body, which leads to decreased perfusion and then eventually to ischemia and infarction. And that does not only pertain to the heart itself, but it also pertains to all the cells in the body that the heart is trying to supply with this oxygen-rich blood. Now in contrast, the diastolic, so the filling pressure, what happens that now there's an increase in pulmonary pressures, which then leads to pulmonary edema, which again the heart is trying to, the body is trying to compensate. And when we have pulmonary edema, the lungs are filled with fluid. Therefore the oxygen exchange doesn't happen the way it's supposed to. Decreased oxygen to the body again leads to ischemia and infarction. And there is about a 60-60% mortality for patients who have cardiogenic shock. So these patients are critically ill and we really need to be very careful in monitoring these patients. So looking at signs and symptoms, once cardiogenic shock develops, the heart rate typically increases because there is this increased need of oxygen supply to all the tissues in the body and the way that the heart tries to compensate is by increasing the heart rate. We will also notice an increase in respiratory rate because we need more oxygen pulled into the body to provide all the cells with the important oxygen. And we might also hear crackles and the increased respiratory rate might be due to crackles if it's due to the pulmonary hypertension or pulmonary edema that we discussed over here. And then skin signs, I cannot emphasize enough how important skin signs are. So pallor, so just the slight maybe decrease in temperature of the patient's skin or maybe they just turn a little bit pale, that means that the perfusion is now impaired. So skin signs are very important. We also might notice that a decrease in capillary refill as the perfusion suffers and is less to the periphery and then we might also notice diminished peripheral pulses such maybe the radial or even a more central pulse like the femoral or coronet pulses. As the heart is suffering and the body is not supplied with the oxygen, all the organs and tissues suffer and particularly the kidneys try to hold on to every bit of fluid that they have to maintain the blood pressure and therefore will see decreased urine output. And as the brain is not being perfused well, we'll see a decreased level in the patient's consciousness. So they might be altered, start trying to be confused, maybe starting to be a little bit combative even. So these are very, very important signs to watch out for in anybody with any of these conditions because the patient might end up in cardiogenic shock. As for diagnostic tests, certainly CBC and CMP are always indicated. Check for blood counts, platelets as well as electrolytes, kidney and liver function. And then certainly we want to look at the troponin because we know the most common cause is because of myocardial infarction. We're going to want to look at the patient's ABGs because now when there is infarction, ischemia, low oxygen, the body might switch over to anaerobic metabolism, which then the kidneys and the respiratory system work together to try and keep the body in a homeostatic state. And we also are going to want to look at the patient's lactic acid or lactate level to see the level of the anaerobic metabolism. We also want to look at the patient's blood glucose level because as the oxygen demand increases, the patient's stress level decreases and so sugars might either be used up or because of the increased release of the cortisol and the production of all the catecholamines that might be an increased blood sugar. And then as for radiologic examinations or diagnostic tests, the chest x-ray certainly will help with any of these conditions as well as an EKG to see the MI or any kind of arrhythmia that the patient is suffering from and echocardiogram to look at the valves and all the structures and also the ejection fraction of the patient as well as a cardiac catheterization or angiogram. Now that is a diagnostic test and actually also a treatment for cardiogenic shock because we know again the most common cause is myocardial infarction, so cardiac catheterization will allow us to visualize the coronary arteries and see the degree of blockage that one or more coronary arteries are currently having so we can visualize that with the angiogram and then either place a stent or open up the disease artery to restore the oxygen to the heart and therefore hopefully resolve this ischemia and possibly even infarction that has developed. And then if the patient is in cardiogenic shock, we want to maximize the stroke volume and the cardio output coming back to our formula here and there are a lot of medications that do that and I have a separate video on cardiac medications that go more into the mechanism of action of these but briefly here, if you want to decrease the workload of the heart and this is due to pulmonary edema we can give the patient nitrates which dilates the coronary arteries and therefore helps with perfusion we can also decrease the preload when there is too much, if this is from a heart failure then if there is too much fluid in the patient system, if they have fluid volume excess we can give them diuretics to get rid of that extra fluid if we want to decrease the apheload then we would give the patient vasodilators to help again ease the workload of the heart if we want to increase the contractility, there is a group of medications called the positive inotropes which helps with the contractility, so help with the force of the contraction that the heart is able to do and the three medications here are the three Ds, so dopamine, dopamine and deoxyn so those are all positive inotropes although they all come with very therapeutic ranges and have to be very carefully titrated or administered because they have certain side effects also that might not be good for a patient with cardiogenic shock and then if you want to decrease the heart rate, so if the reason is a tachyarrhythmia here we certainly could give the patient beta blockers to help take off or decrease the workload of the heart here and other treatment modalities are albat which is a left ventricular assist device so this is more of a, typically it's used as a modality as a bridge to heart transplant for patients with severe congestive heart failure with a very very low ejection fraction or a balloon pump to help the workload of the heart and increase the cardiac output to maximize it and then if it all else fails and the patient is a candidate, a heart transplant is an option and then as for nursing care, so as I already mentioned, these patients are very very ill and they will be an intensive care unit and it always comes down to monitoring our ABCs and when the patient is in the ICU and they're critically ill most likely they will be intubated so we have to monitor their artificial airway as well as the ventilator and any kind of settings associated with that and then we have to frequently assess the lung sounds because they will give us a good indication as to what's going on with the relationship between the heart and the lungs and any kind of fluid backup or if the patient is very sensitive to fluid administration remember that we always have to assess the lung sounds to make sure that the patient is not developing pulmonary edema and then hemodynamic monitoring, certainly the patient might have an arterial line to monitor blood pressure or a central venous line to monitor the fluid status and you can watch my separate videos about those modalities as well and then frequent assessment and reassessment is really key here so that we can detect changes very rapidly and then also adjust any of these medications that the patient needs so that they hopefully can get over this episode of this cardiogenic shock so frequent assessment includes the lungs and the skin for all these signs that I've mentioned here but also the hearing output because we know the kidneys need blood flow to be able to work and it will also give us an indication of the patient's fluid volume status as well as their level of consciousness depending on their sedation status if they're intubated we want to also assess their GI system because again if there is no perfusion and the GI system might suffer it might become ischemic we also want to watch out for personal hygiene specifically if the patient is intubated good oral hygiene and pulmonary hygiene really are important to make sure that no secondary infection develops and then meticulous skin and oral care to prevent all these effects of immobility because again like I mentioned that these patients are critically ill and will be immobile or ventilator and will depend on us to take care of all their day-to-day needs and skin care certainly as we know is super important here so thank you very much for watching this video on cardiogenic shock please also see the other videos in the critical care playlist that not only talk about these topics here that can lead to cardiogenic shock but also the ones about cardiac output as well as the cardiac medications the intubation and hemodynamic videos as well as the other shocks such as septic shock, neurogenic shock, hypovolemic shock and anaphylactic shock thanks for watching please give me the thumbs up if you enjoyed the video and I'll see you soon right here on your sinks full explained