This presentation can help you understand the concept of Cardiogenic Shock more. It contains Definition, Causes, Risk Factors, Signs and Symptoms, Prevention, Prognosis, and Pathophysiology. Cardiogenic Shock is a type of Shock wherein the main cause of problem is the inability of the heart itself to pump out the blood making the heart's workload and pressure increase.

1. CARDIOGENIC
SHOCK
PREPARED BY:
BSN 4-A
STUDENT MONITORING GROUP 3
ETHEL RHICA CABUSLAY
BEA JEWELLE B. FONTANILLA
KAREN ANDREA G. ALBENIA
RONALYN A. MONFORTE
ROXANNE M. TUMALE
KENNETH KLEI E. VIDAD

2. OVERVIEW
Cardiogenic shock is a condition caused by the inability of the heart
to pump blood sufficiently to meet the metabolic needs of the body
due to the impaired contractility of the heart. Clients usually
manifest signs of low cardiac output, with adequate intravascular
volume. It is usually associated with myocardial infarction (MI),
cardiomyopathies, dysrhythmias, valvular stenosis, massive
pulmonary embolism, cardiac surgery, or cardiac tamponade. It is a
self-perpetuating condition because coronary blood flow to the
myocardium is compromised, causing further ischemia and
ventricular dysfunction.

3. OVERVIEW
Cardiogenic shock occurs as a serious complication in 5% to
10% of patients hospitalized with acute myocardial
infarction. Historically, mortality for cardiogenic shock had
been 80% to 90%, but recent studies indicate that the rate
has dropped to 56% to 67% due to the advent of
thrombolytics, improved interventional procedures, and
better therapies.
Incidence of cardiogenic shock is more common
in men than in women because of their higher
incidence of coronary artery disease.

4. DEFINITION
According to the National Institutes of Health, Cardiogenic shock, also known as cardiac shock,
happens when your heart cannot pump enough blood and oxygen to the brain and other vital
organs. This is a life-threatening emergency. It is treatable if diagnosed right away, so it’s
important to know the warning signs.
Without oxygen-rich blood reaching the brain and other vital organs, your blood pressure
drops, and your pulse slows. You may have symptoms such as confusion, sweating, and rapid
breathing. You may also lose consciousness.
According to Journal of the American Heart Association (JAHA), Cardiogenic shock (CS) is a
common cause of mortality, and management remains challenging despite advances in
therapeutic options. CS is caused by severe impairment of myocardial performance that
results in diminished cardiac output, end‐organ hypoperfusion, and hypoxia.1 Clinically this
presents as hypotension refractory to volume resuscitation with features of end‐organ
hypoperfusion requiring pharmacological or mechanical intervention.1 Acute myocardial
infarction (MI) accounts for 81% of patient in CS.

5. CAUSES OF
CARDIOGENIC
SHOCK
 Damaged heart muscle from
having a heart attack
 myocarditis
 endocarditis
 arrhythmia
 cardiac tamponade
 pulmonary embolism
 Weakened heart from any
cause
 Drug overdoses or poisoning
with substances that can
affect your heart's pumping
ability
 A heart valve problem,
 Damage to the septum that
divides the left and right
ventricles of your heart.
 Heart failure
 Injury to your chest

9. RISK FACTORS
 Are older
 Are female
 Have a history of heart
failure or heart attack
 Have blockages
(coronary artery
disease) in several of
your heart's main
arteries
 High blood pressure.
 High cholesterol.
 Diabetes.
 Use of tobacco products.
 Overweight and obesity.
 A prior coronary artery
bypass graft.
 Lack of exercise.

10. STAGES OF CARDIOGENIC
SHOCK
Compensated Stage
Decompensated Stage
Progressive Stage
Refractory Stage
Cardiogenic shock generally advances through multiple stages as the heart's contractile function
declines. The severity of these stages may differ among individuals, and prompt intervention is
imperative to impede progression towards more severe phases. Potential stages of cardiogenic
shock comprises of:

11. SIGNS AND SYMPTOMS OF
CARDIOGENIC SHOCK
• Hypotension (Low Blood Pressure)
• Rapid Heart Rate (Tachycardia)
• Cold and Clammy Skin
• Weak Pulse
• Shortness of Breath (Dyspnea)
• Confusion or Altered Mental Status.
• Chest Pain or Discomfort
• Fatigue and Weakness
• Reduced Urine Output
• Nausea and Vomiting

12. MEDICAL
MANAGEMENT
1. Oxygen Therapy
Definition: oxygen therapy is the administration of oxygen at a
concentration of pressure greater than that found in the environmental
atmosphere.
Purpose: To increase oxygen saturation in tissues where the saturation
levels are too low due to illness or injury.
Procedure:
Before the Procedure:
 Verify provider order or protocol.
 Gather supplies: pulse oximeter, oxygen delivery device, and tubing.
 Perform hand hygiene.
 Introduce yourself, your role, the purpose of your visit, and an estimate of
the time it will take.

13. MEDICAL
MANAGEMENT
 Confirm patient ID using two patient identifiers (e.g., name and date of
birth).
 Explain the process to the patient and ask if they have any questions.
 Ensure the patient’s privacy and dignity.
 Perform a focused respiratory assessment including airway, respiratory rate,
pulse oximetry rate, and lung sounds.
During the Procedure:
 Employ safety measures for oxygen therapy.
 Connect flow meter to oxygen supply source.
 Apply adapter for tubing.
 Connect nasal cannula tubing to flow meter.
 Set oxygen flow at prescribed rate.

14. After the Procedure:
 Assist the patient to a comfortable position.
 Ensure safety measures when leaving the room:
o CALL LIGHT: Within reach
o BED: Low and locked (in lowest position and brakes on)
o SIDE RAILS: Secured
o TABLE: Within reach
o ROOM: Risk-free for falls (scan room and clear any obstacles)
 Perform hand hygiene.
 Document the assessment findings. Report any concerns according to
agency policy.
MEDICAL
MANAGEMENT

15.  Assessing the patient’s skin and mucus membranes, breathing patterns,
chest movements, lung sounds, presence of clinical signs of hypoxemia
and oxygen toxicity.
 Assessing the patient's oxygenation status and vital signs
 Selecting the appropriate oxygen delivery device and flow rate
 Humidifying the oxygen to prevent drying of the mucous membranes
 Monitoring the patient's response and adjusting the therapy as needed
 Checking for potential safety hazards and ensuring proper use of
equipment
 Educating the patient and family about the benefits and risks of oxygen
therapy
 Documenting the interventions and observations
NURSING
RESPONSIBILITY

16. 2. INTRAVENOUS FLUID THERAPY
Description: Lactated Ringer’s solution, or LR, is an intravenous (IV) fluid you
may receive if dehydrated, having surgery, or receiving IV medications.
Purpose: To replace water and electrolyte loss in patients with low blood
volume or low blood pressure
Procedure:
Before Procedure:
•Provide informed consent to the patient or significant others.
•Review physician’s order.
MEDICAL
MANAGEMENT

17. Perform hand hygiene procedures.
•Prepare and gather the equipment needed for starting the IV.
•Assessment the patient and psychological preparation.
•Site selection and vein dilation.
MEDICAL
MANAGEMENT
During Procedure:
•Needle selection.
•Don your gloves.
•Once you’ve donned your gloves, you’ll be now preparing the site of
insertion.
•Insertion of catheter into vein.
•Catheter stabilization and dressing management.

18. After Procedure:
•Needles and stylets shall be disposed of in non-permeable tamper-proof
containers. Dispose of all paper and plastic equipment in a biohazard
container.
•Patient must receive information on all aspects of their care. After catheter
is stabilized, dressing is applied, and labeling complete.
•Ensure appropriate infusion flow. Do not leave patient care environment
until rate is calculated and adjusted accordingly.
•Document the relevant data, including assessments.
MEDICAL
MANAGEMENT

19. • Verify Doctor’s Order
• Prime IV tubing to expel air to prevent air embolism
• Instruct the patient that the procedure may cause a little bit
pain upon insertion
• Regulate IVF at prescribed rate.
• Use sterile technique when preparing and administering of
fluid and medication.
• Check IV patency.
• Discard unused portion
NURSING
RESPONSIBILITY

20. 3. Hemodynamic Monitoring
Definition: Hemodynamic monitoring refers to close observation of the
functions of the cardiovascular system and circulatory status of critically ill
patients.
Purpose:
 To maintain adequate perfusion of the internal organs
 early identification of preventable complications and life-threatening
conditions (e.g., heart failure)
 To guide course of treatment and administration of fluids
 To accurately determine the effectiveness of therapeutic interventions
 To precisely assess the cardiovascular function of the critically ill patients
MEDICAL
MANAGEMENT

21. MEDICAL MANAGEMENT
Procedure:
 Mix 1,000 units of heparin into 500 cc bag of normal saline.
 Label bag with date and added medication.
 Tighten all connections on pressure tubing.
 Spike NS bag and remove air from bag.
 Insert pressure tubing spike into NS bag securely.
 Fill drip chamber of tubing halfway. Place pressure bag around NS bag.
 Flush pressure tubing and all ports completely prior to inflating pressure bag.
 Inflate pressure bag to 300 mm Hg.
 Mount bag and transducer onto IV pole.
 Leveling the Transducer: Position the patient supine. Identify the phlebostatic
axis (4th intercostal space, midaxillary line).
 Mark phlebostatic axis with indelible marker.
 Level the membrane of the transducer directly to the marked phlebostatic axis
on the side of the patient's chest.

22. NURSING RESPONSIBILITY
 Assisting with insertion and removal of invasive hemodynamic lines.
 Monitoring heart rate and rhythm.
 Zeroing and calibrating equipment every 4 to 12 hours, as
appropriate, with transducer at the level of the right atrium to
ensure accuracy of waveform.
 Other nursing responsibilities may include assessing the client for
decreased cardiac output, identifying cardiac rhythm strip
abnormalities, applying a knowledge of pathophysiology to
interventions in response to client abnormal hemodynamics, and
providing the client with strategies to manage decreased cardiac
output.

23. PHARMACOLOGICAL MANAGEMENT
1. Dobutamine
Mechanism of action:
Adrenergic direct-acting cardiac stimulant; produces inotropic effects by
stimulating myocardial beta-receptors, increasing strength of myocardial activity
and improving cardiac output.
 Increase cardiac contractility
 Increases cardiac output without increasing the heart rate
Nursing responsibilities:
 Assess for hypovolemia to prevent complications, such as hypotension, organ
dysfunction, or arrhythmias, which can occur when dobutamine is administered
without considering the patient's fluid status.
 Monitor BP, chest pain, LOC
 If BP increases, titrate the value. Based on the patient hemodynamics and renal
response

24. 2. Dopamine
Mechanism of action:
 Andrenergic agent
 Vasoconstrictor and inotropic effect
 Causes increase cardiac output, renal blood flow and sodium excretion
Nursing responsibilities:
 Assess for hypovolemia to prevent complications, such as hypotension, organ
dysfunction, or arrhythmias, which can occur when dobutamine is administered
without considering the patient's fluid status.
 Monitor BP, chest pain, LOC
 If BP increases, titrate the value. Based on the patient hemodynamics and renal
response
 Administer only by IV. NO BOLUS. Administering dopamine as an infusion
minimizes the risk of adverse effects, such as arrhythmias or excessive
vasoconstriction.
PHARMACOLOGICAL MANAGEMENT

25. 3. Epinephrine
Mechanism of action:
Alpha-adrenergic vasoconstriction
 Can reduce bleeding
 Mydriasis
Beta-2 adrenergic-bronchial relaxation
Nursing responsibilities:
 Proper labelling
 Continous monitoring
 Check bp & pr every Q15
 After giving flush it immediately with 3-5ml of NSS
 Ensure proper heart rhythm and watch carefully
PHARMACOLOGICAL MANAGEMENT

26. 4. Norepinephrine
Adrenergic agent
Vasoconstrictor and inotropic effect
(Causes increased BP, heart rate, and cardiac
output)
NURSING RESPONSIBILITIES
• Assess continuously for BP every 5 minutes
• If BP increases, titrate the dose
• If urine output is 30 ml/hour, notify the physician
PHARMACOLOGICAL MANAGEMENT

27. PHARMACOLOGICAL MANAGEMENT
5. Vassopressin
Mechanism of action:
Causes contraction of smooth muscle in the vascular bed and
increases systemic vascular resistance and mean arterial BP and
decrease HR and cardiac output.
Nursing responsibilities:
 Monitor BP Q15
 Monitor I&O
 Monitor ECG and fluid and electrolytes status
 Monitor signs and symptoms of ischemia

28. PHARMACOLOGICAL MANAGEMENT
6. Nitroglycerin
Mechanism of action:
Reduces cardiac oxygen demand by decreasing left
ventricular end-diastole pressure and to lesser extent,
systematic vascular resistance. Also increase blood flow
through the collateral coronary vessels.
Nursing interventions:
 Closely monitor vs particularly BP, during infusion,
especially in patient with an MI. Excessive hypotension
can worsen ischemia.

29. SURGICAL
MANAGEMENT
Intra-aortic balloon pump (IABP).The IABP is a mechanical-assist
device that attempts to improve the coronary artery perfusion and
decrease cardiac workload through an inflatable balloon pump
which is percutaneously or surgically inserted through the femoral
artery into the descending thoracic aorta.

30. NURSING
MANAGEMENT
 Preventing cardiogenic shock. Identifying at-risk patients early, promoting
adequate oxygenation of the heart muscle, and decreasing cardiac workload can
prevent cardiogenic shock. This can be accomplished by conserving the patient's
energy, promptly relieving angina, and administering supplemental oxygen.
 Monitoring Hemodynamic Status. A major role of the nurse is monitoring the
patient's hemodynamic and cardiac status. Arterial lines and ECG monitoring
equipment must be well maintained and functioning properly. Changes in
hemodynamic, cardiac, and pulmonary status and laboratory values are
documented and reported promptly.

31. NURSING
MANAGEMENT
 Administering medications and intravenous fluids. The nurse must
be knowledgeable about the desired effects as well as the side
effects of medications. Arterial and venous puncture sites must be
observed for bleeding, and pressure must be applied at the sites if
bleeding occurs. IV infusions must be observed closely because
tissue necrosis and sloughing may occur if vasopressor medications
infiltrate the tissues. When possible, vasoactive medications should
be given using central IV lines. should be reviewed daily to reduce
the risk of CLABSIs

32. NURSING
MANAGEMENT
 Maintaining Intra-Aortic balloon counterpulsation. The
nurse makes ongoing timing adjustments of the balloon
pump to maximize its effectiveness by synchronizing it
with the cardiac cycle. therefore, the nurse must check
the neurovascular status of the lower extremities
frequently.

33. NURSING
MANAGEMENT
 Enhancing safety and comfort. The nurse must take an active role
in safeguarding the patient, enhancing comfort, and reducing
anxiety. This includes administering medication to relieve chest
pain, preventing infection at the multiple arterial and venous line
insertion sites, protecting the skin, and monitoring respiratory and
renal function. Proper positioning of the patient promotes
effective breathing without decreasing BP and may also increase
patient comfort while reducing anxiety.

34. DIAGNOSTIC EXAMINATIONS
Purpose: to help diagnose many common heart problems. A health care
provider might use an electrocardiogram to determine or detect:
Irregular heart rhythms (arrhythmias)
If blocked or narrowed arteries in the heart (coronary artery disease) are
causing chest pain or a heart attack
Whether you have had a previous heart attack
ELECTROCARDIOGRAM (ECG OR EKG)
Definition: The ECG is a graphic representation of the electrical currents of
the heart. The ECG is obtained by placing disposable electrodes in standard
positions on the skin of the chest wall and extremities. Recordings of the
electrical current flowing between two electrodes are made on graph paper
or displayed on a monitor. An electrocardiogram is a painless, and
noninvasive

35. PROCEDURE:
1. Patient Assessment: Assess the patient's medical history, current symptoms, and any
contraindications or allergies to materials used during the procedure.
2. Informed Consent: Explain the procedure to the patient, including its purpose, potential
risks, and obtain informed consent.
3. Patient Preparation: Ensure that the patient is comfortable and relaxed. Explain that they
will need to lie still during the test.
PRE-PROCEDURE NURSING MANAGEMENT:
During the ECG Procedure:
1. Proper Patient Positioning: Have the patient lie down on an examination
table or bed. For a standard 12-lead ECG, position the patient flat on their
back.
2. Skin Preparation: Ensure the skin is clean and dry. Shave any excessive hair if
necessary, as hair can interfere with electrode placement.

36. 3. Electrode Placement: Attach ECG electrodes to specific locations on the chest,
limbs, and sometimes the precordial (front) area of the chest. Ensure good electrode-
skin contact.
4. Electrode Lead Placement: Connect the electrodes to the ECG machine following
the correct lead placement configuration.
5. Monitor and Record: Start the ECG machine to record the electrical signals.
Monitor the patient throughout the procedure for any signs of discomfort or adverse
reactions.
1. Remove Electrodes: Carefully remove the ECG electrodes, ensuring that they
do not cause skin irritation or damage.
2. Document the ECG: Record the ECG results, ensuring that the time and date
are accurately documented.
3. Patient Comfort: Assist the patient in sitting up and provide any necessary
support.
Post-Procedure Nursing Management:

37. 4. Educate the Patient: Explain to the patient that the ECG results will be
reviewed by a healthcare provider, and they will receive feedback on the
findings.
5. Monitor for Adverse Reactions: Continue to monitor the patient for any
delayed reactions or discomfort.
6. Ensure Privacy: Respect the patient's privacy and dignity throughout
the procedure.
Nursing management: during an ECG procedure involves not only
technical skills but also a patient-centered approach to ensure the patient's
well-being, comfort, and understanding. It is essential to be prepared for
any unexpected events or complications and to provide the appropriate
support and care during the procedure.

38. Normal Sinus Rhythm
Electrical conduction that begins in the SA node generates a sinus rhythm. Normal
sinus rhythm occurs when the electrical impulse starts at a regular rate and rhythm in
the SA node and travels through the normal conduction pathway. Normal sinus rhythm
has the following characteristics:
Ventricular and atrial rate: 60 to 100 bpm in the adult
Ventricular and atrial rhythm: Regular
Normal results
QRS shape and duration: Usually normal, but may be regularly abnormal
P wave: Normal and consistent shape; always in front of the QRS
PR interval: Consistent interval between 0.12 and 0.20 seconds
P:QRS ratio: 1:1
Normal sinus rhythm is generally indicative of good cardiovascular health. However, an
increase of 10 bpm or more in the resting heart rate increases the risk for sudden
cardiac death, atrial fibrillation, heart failure, coronary artery disease.

39. Definition: is a common invasive procedure used to
diagnose structural and functional diseases of the heart
and great vessels. The results guide treatment decisions
including the need for revascularization (PCI or CABG) and
other interventions to manage structural defects of the
valves or septum.
CARDIAC CATHETERIZATION
Two types of Cardiac Catheterization:
Right Heart Catheterization – it is performed to assess the function of the
right ventricle and tricuspid valves.
Left Heart Catheterization – is performed when to evaluate the aortic arch and
its major branches, patency of the coronary arteries, and the function of the left
ventricle and mitral and aortic valves.

40. 1.Diagnosing Heart Conditions: Cardiac catheterization is commonly used to diagnose a
wide range of heart conditions, including coronary artery disease, heart valve problems,
congenital heart defects, and other structural abnormalities within the heart.
2.Assessing Coronary Arteries: Cardiac catheterization is especially useful for evaluating the
coronary arteries, which supply blood to the heart muscle.
3.Measuring Pressure and Oxygen Levels: The catheter used in this procedure can also
measure pressures within the heart's chambers and blood vessels.
4.Treating Heart Conditions: In addition to its diagnostic role, cardiac catheterization can be
therapeutic. Procedures such as angioplasty and stent placement are often performed
during a cardiac catheterization to open narrowed or blocked coronary arteries, improving
blood flow to the heart muscle.
5.Guiding Electrophysiological Studies: In some cases, cardiac catheterization is used to
guide electrophysiological studies, which help diagnose and treat abnormal heart rhythms
(arrhythmias).
Purpose:

41. Procedure: This procedure involves the percutaneous insertion of
radiopaque catheters into a large vein and an artery. Fluoroscopy is used to
guide the advancement of the catheters through the right and left heart,
referred to as right and left heart catheterizations, respectively. In most
situations, patients undergo both right and left heart catheterizations.
RIGHT HEART CATHETERIZATION is performed without a left heart
catheterization when patients only need myocardial biopsies or
measurement of pulmonary artery pressures.

42. LEFT HEART CATHETERIZATION involves the use of a contrast agent.
These agents are necessary to visualize patency of the coronary arteries
and evaluate left ventricular function. In preparation for the procedure,
patients have blood tests performed to evaluate metabolic function
(electrolytes and glucose) and renal function (blood urea nitrogen and
creatinine level).
Baseline coagulation studies (activated partial thromboplastin time
[aPTT], international normalized ratio [INR], and prothrombin time [PT])
are obtained to guide dosing of anticoagulation during the procedure.
Because bleeding and hematoma formation are procedural risks, a
complete blood cell count (CBC; includes the hematocrit, hemoglobin,
and platelets) is necessary to establish baseline values. Later these results
are compared with post-procedure results to monitor for blood loss.

43. During a cardiac catheterization, the patient has one or more IV catheters for
administration of fluids, sedatives, heparin, and other medications. The patient is
continuously monitored for chest pain or dyspnea and for changes in BP and ECG, which
are indicative of myocardial ischemia, hemodynamic instability, or arrhythmias.
Resuscitation equipment must be readily available, and staff must be prepared to pro-
vide advanced cardiac life support measures as necessary.
Post-procedure, patients remain on bed rest for 2 to 6 hours before they are permitted to
ambulate. Variations in time to ambulation are related to the size of the catheters used
during the procedure, the site of catheter insertion (femoral or radial artery), the patient's
anticoagulation status, and other factors (e.g., advanced age, obesity, bleeding disorder).
The use of a radial access site and smaller (4- or 6-Fr) arterial catheters are associated with
shorter bed rest restrictions. Cardiac catheterization may be performed in the ambulatory
setting. Unless the results demonstrate the need for immediate treatment, patients are
discharged home. Hospital- ized patients undergoing cardiac catheterization for
diagnostic and interventional purposes (PCI, valvuloplasty) are returned to their hospital
rooms for recovery.

44. RIGHT HEART CATHETERIZATION PROCEDURE: involves the passage of a
catheter from a brachial, internal jugular, or femoral vein into the right atrium,
atrium, right ventricle, pulmonary artery, and pulmonary arterioles. Pressures,
and oxygen saturations from each of these areas are obtained and recorded.
The pulmonary artery pressures are used to diagnose pulmonary
hypertension. A biopsy of a small piece of myocardial tissue can also be
obtained during a right heart catheterization. The results of the biopsy are
used to diagnose the etiology of a cardiomyopathy (abnormality of
myocardium) or heart transplant rejection. At the completion of the
procedure, the venous catheter is removed and hemostasis of the affected
vein is achieved using manual pressure. Although right heart catheterization
is considered relatively safe, potential complications include arrhythmias
(from contact of the catheter with the endocardium), venous spasm, infection
at the insertion site, and right heart perforation.

45. LEFT HEART CATHETERIZATION PROCEDURE: performed by retrograde catheterization of
the left ventricle. In this approach, the interventional cardiologist usually inserts the
catheter into the right radial or a femoral artery and advances it into the aorta and left
ventricle.
During a left heart catheterization, angiography is performed.
ANGIOGRAPHY is an imaging technique that involves the injection of the contrast agent
into the arterial catheter. The contrast agent is filmed as it passes through the chambers of
the left heart, aortic arch, and its major arteries.
CORONARY ANGIOGRAPHY is another technique used to observe the coronary artery
anatomy and evaluate the degree of stenosis from atherosclerosis. To perform this test, a
catheter is positioned into one of the coronary arteries. Once in position, the contrast
agent is injected directly into the artery and images are obtained. The procedure is then
repeated using the oppo- site coronary artery.
VENTRICULOGRAPHY is also performed to evaluate the size and function of the left
ventricle. For this test, a catheter is positioned in the left ventricle and a large amount of
contrast agent (30 mL) is rapidly injected into the ventricle

46. The manipulation of catheters in the coronary arteries and left ventricle as well as
injection of the contrast agent can cause intermittent myocardial ischemia.
Vigilant monitoring throughout left heart catheterization is needed to detect
myocardial ischemia, which can trigger chest pain and life-threatening arrhythmias.
PROCEDURE IS COMPLETED, the arterial catheter is withdrawn. There are several
options available to achieve arterial hemostasis, including applying manual pressure
and hemostatic devices available from numerous vendors.
RADIAL ARTERY, a compression device, such as the Terumo TR Band, is positioned
over the artery. It has a mechanism that is inflated with air to put pressure against
the artery. It remains in place for about 2 hours.
FEMORAL APPROACH, manual pressure may be used alone or in combination with
mechanical compression devices such as the FemoStop.

47. BEFORE CARDIAC CATHETERIZATION:
 Instructing the patient to fast, usually for 8 to 12 hours, before the procedure.
 Informing the patient that if catheterization is to be performed as an
outpatient procedure, a friend, family member, or other responsible person
must transport the patient home. Informing the patient about the expected
duration of the procedure and advising that it will involve lying on a hard
table for less than 2 hours.
 Reassuring the patient that IV medications are given to maintain comfort.
Informing the patient about sensations that will be experienced during the
catheterization. Knowing what to expect can help the patient cope with the
experience.
NURSING MANAGEMENT:

48.  The nurse explains that an occasional pounding sensation (palpitation) may
be felt in the chest because of extra heartbeats that almost always occur,
particularly when the catheter tip touches the endocardium. The patient
may be asked to cough and to breathe deeply, especially after the injection
of the contrast agent. Coughing may help disrupt an arrhythmia and clear
the contrast agent from the arteries. Breathing deeply and holding the
breath help lower the diaphragm for better visualization of heart structures.
The injection of a contrast agent into either side of the heart may produce a
flushed feeling throughout the body and a sensation similar to the need to
void, which subsides in 1 minute or less.
 Encouraging the patient to express fears and anxieties.
 The nurse provides education and reassurance to reduce apprehension.
NURSING MANAGEMENT:

49.  NURSING RESPONSIBILITIES AFTER CARDIAC CATHETERIZATION are guided by
hospital policy and primary provider preferences and may include:
 Observing the catheter access site for bleeding or hematoma formation and
assessing peripheral pulses in the affected extremity (dorsalis pedis and
posterior tibial pulses in the lower extremity, radial pulse in the upper extremity)
every 15 minutes for 1 hour, every 30 minutes for 1 hour, and hourly for 4 hours
or until discharge. BP and heart rate are also assessed during these same time
intervals.
 Evaluating temperature, color, and capillary refill of the affected extremity
during these same time intervals. The patient is assessed for affected extremity
pain, numbness, or tingling sensations that may indicate arterial insufficiency.
The best technique to use is to compare the examination findings between the
affected and unaffected extremities. Any changes are reported promptly.
NURSING MANAGEMENT:

50.  Screening carefully for arrhythmias by observing the cardiac monitor or by assessing the
apical and peripheral pulses for changes in rate and rhythm. A vasovagal reaction,
consisting of bradycardia, hypotension, and nausea, can be precipitated by a distended
bladder or by discom fort from manual pressure that is applied during removal of an
arterial or venous catheter. The vasovagal response is reversed by promptly elevating the
lower extremities above the level of the heart, infusing a bolus of IV fluid. and
administering IV atropine to treat the bradycardia.
 Maintaining activity restrictions for 2 to 6 hours after the procedure. The determination of
bed rest, chair activity, and time to commence ambulation is dependent upon location of
arterial approach, size of the catheter used during the procedure, medications
administered, and method used to maintain hemostasis. If manual pressure or a
mechanical device was used during a femoral artery approach, the patient remains on bed
rest for up to 6 hours with the affected leg straight and the head of the bed elevated no
greater than 30 degrees. For comfort, the patient may be turned from side to side with the
affected extremity straight.
NURSING MANAGEMENT:

51. If a percutaneous vascular closure device or patch was deployed, the nurse
checks local nursing care standards and anticipates that the patient will have
fewer activity restrictions. If the radial closure device was used, the patient can
sit up in a chair until the effects of sedation have dissipated, and early
ambulation is encouraged. After the vascular closure device removal, a dressing
is applied over the catheter access site. Patients can return to normal activities
the day after the procedure but must avoid strenuous wrist activities for several
days (Mason et al., 2018). Analgesic medication is given as prescribed for
discomfort.
NURSING MANAGEMENT:
 Instructing the patient to report chest pain and bleeding or
sudden discomfort from the catheter insertion sites promptly.

52.  Monitoring the patient for CIN by observing for elevations in serum
creatinine levels. IV hydration is used to increase urinary output and
flush the contrast agent from the urinary tract; accurate oral and IV
intake and urinary output are recorded.
 Ensuring patient safety by instructing the patient to ask for help when
getting out of bed the first time after the procedure. The patient is
monitored for bleeding from the catheter access site and for
orthostatic hypotension, indicated by complaints of dizziness or
lightheadedness.
 For patients being discharged from the hospital on the day as the
procedure, additional instructions are provided
NURSING MANAGEMENT:

53. Normal Results:
Normal results in a cardiac catheterization, also known as a coronary angiography, typically indicate that there
are no significant blockages, abnormalities, or structural defects in the coronary arteries or heart chambers.
Here are some common normal findings during a cardiac catheterization:
Normal Coronary Arteries: The coronary arteries, which supply blood to the heart muscle, appear
unobstructed without significant narrowing or blockages. There is a smooth flow of blood through these
vessels.
Normal Heart Chambers: The four chambers of the heart (left atrium, left ventricle, right atrium, and right
ventricle) appear to be of typical size and function, with no significant structural defects.
Normal Heart Valve Function: The heart valves, including the aortic, mitral, tricuspid, and pulmonic valves,
function without significant regurgitation (leakage) or stenosis (narrowing).
Normal Ejection Fraction: The ejection fraction (EF), which measures the heart's pumping ability, is within a
normal range. A normal EF is typically above 50% to 55%.
Absence of Coronary Artery Disease: The images produced during the procedure do not show any significant
plaque buildup or atherosclerosis in the coronary arteries.
Absence of Congenital Defects: There are no structural abnormalities or congenital defects within the heart,
such as atrial or ventricular septal defects.

54. Definition: A chest X-ray may be performed to assess the size and
shape of the heart, as well as to identify any lung congestion or
signs of pulmonary edema
Purpose:
 Detecting Congestion and Pulmonary Edema
 Assessing Cardiac Enlargement
 Differentiating Causes
 Monitoring Response to Treatment
CHEST X-RAY:

55. Pre-Procedure Nursing Management
 Patient Assessment: Assess the patient's medical history, including
allergies, previous X-rays, and any current symptoms. It's important to
identify any potential contraindications or special considerations.
 Informed Consent: Explain the procedure to the patient, including its
purpose and potential risks. Obtain informed consent if required.
 Patient Education: Provide information to the patient about the
procedure, including any specific instructions, such as the need to remove
jewelry, clothing, or accessories that could interfere with the X-ray.
 Radiation Safety: Ensure that the patient, nursing staff, and anyone else in
the vicinity are appropriately shielded from radiation.
Procedure:

56. During the Chest X-ray Procedure:
 Positioning: Instruct the patient on how to position themselves appropriately. The
patient will usually stand facing the X-ray machine with their chest against a detector
plate, or they may sit or lie down on an X-ray table depending on the clinical scenario.
 Protection: Provide the patient with a lead apron and thyroid shield to protect from
unnecessary radiation exposure. If the patient is unable to move or stand, the radiologic
technologist may need to assist in positioning.
 Immobilization: Ensure that the patient remains still during the X-ray to avoid blurriness
in the images. Pediatric patients or those with limited mobility may require additional
assistance.
 Communication: Maintain communication with the patient throughout the procedure to
address any concerns or discomfort. In some cases, the patient may be asked to hold
their breath briefly during image capture.
Post-Procedure Nursing Management:
 Patient Comfort: Assist the patient in getting up from the X-ray table or repositioning them
as needed. Provide any necessary support, as some patients may feel lightheaded after
standing up.

57.  Radiation Safety: Ensure that all protective equipment, such as lead aprons and shields,
are properly removed and stored.
 Review Images: The radiologic technologist will process and review the X-ray images. The
results will be sent to the physician for interpretation.
 Patient Discharge: If the patient is an outpatient, they can typically resume their normal
activities after the procedure, unless otherwise instructed by their healthcare provider.
 Documentation: Document the procedure in the patient's medical record, including the
date and time, any issues or patient reactions, and any additional information relevant to
the procedure.
Normal Results: Heart: The heart should be of a normal
size and shape, situated within the mediastinum. The
borders of the heart, including the left and right
ventricles and atria, should be well-defined.

58. Abnormal Result:
 Pulmonary Edema: Cardiogenic shock often leads to pulmonary edema, which is the accumulation of fluid
in the air sacs of the lungs. On an X-ray, this is seen as increased lung density, resulting in a "butterfly" or
"bat-wing" pattern. The lungs appear hazy and filled with fluid, indicating severe congestion.
 Cardiomegaly: An enlarged heart, or cardiomegaly, is frequently observed in cardiogenic shock. The heart
may appear larger than normal, with an increased cardiac silhouette on the X-ray.
 Kerley B Lines: These are short, horizontal lines seen on a chest X-ray. They may indicate interstitial edema,
which is often associated with cardiogenic shock and congestive heart failure. Kerley B lines result from the
fluid accumulating in the interstitial spaces of the lung.
 Alveolar Filling Defects: Alveolar opacities may be present in cases of severe cardiogenic shock, which can
indicate fluid or blood in the alveoli (the air sacs in the lungs). These opacities can manifest as white, patchy
areas on the X-ray.
 Hydrostatic Pulmonary Edema Signs: These include cephalization of vessels (enlarged upper lung vessels),
an enlarged cardiac silhouette, and pleural effusions (fluid in the pleural space). These findings may appear
on the X-ray as signs of fluid overload in the chest.
 Pleural Effusion: In some cases, pleural effusions (fluid in the pleural space) can be seen, which can further
compromise lung function and contribute to respiratory distress.

59. Definition: An echocardiogram is a crucial diagnostic tool for evaluating the structure and
function of the heart.
Purpose: It can reveal abnormalities in heart valves, wall motion, and overall cardiac function.
Procedure:
Preparation:
 Patient Assessment: The nurse begins by assessing the patient's medical history, including
any known heart conditions, allergies, and current symptoms. This assessment helps tailor
the procedure and address specific patient needs.
 Patient Education: The nurse explains the purpose of the echocardiogram, the procedure,
and any potential risks or discomfort. They provide information on what to expect during
the test.
ECHOCARDIOGRAM (CARDIAC
ULTRASOUND):

60.  Informed Consent: Ensure that the patient understands the procedure and obtains
informed consent if necessary, especially for transesophageal echocardiograms
(TEEs), which may require sedation.
 Gown and Privacy: Provide a hospital gown for the patient to change into. Ensure
the patient's privacy and modesty are maintained.
 Electrode Placement: Apply ECG electrodes to monitor the patient's heart rhythm
during the procedure. These electrodes are connected to an ECG machine.
Conducting the Echocardiogram:
 Positioning: Assist the patient in getting into the appropriate position, which
may include lying on their left side, back, or sitting up, depending on the type
of echocardiogram being performed.
 Gel Application: The nurse may help apply the clear gel to the chest to
improve the sound wave transmission and ensure good contact with the
transducer.

61.  Transducer Placement: The sonographer, who performs the echocardiogram,
moves the transducer over the chest and uses a gentle amount of pressure
to obtain images. Nursing staff can help ensure the patient remains
comfortable during this process.
 Patient Comfort: Monitor the patient's comfort and address any concerns or
discomfort they may experience during the procedure. Keep the patient
informed about the progress of the test.
Post-Procedure:
 Gel Removal: After the echocardiogram is complete, assist the patient in
cleaning the gel from their chest.
 Return to Normal Activities: Once the procedure is done, the patient can
usually resume their regular activities immediately. There is no downtime or
recovery period.

62. Nursing Management Considerations:
 Nursing staff should be knowledgeable about the different types of echocardiograms
and the specific patient preparation required for each.
 Nurses play a key role in explaining the procedure to patients, addressing any questions
or concerns, and ensuring informed consent is obtained if necessary.
 In the case of transesophageal echocardiograms (TEEs), which may require sedation, the
nurse should monitor the patient's vital signs and level of consciousness during the
procedure.
 For patients with mobility or positioning challenges, the nurse can assist in ensuring the
patient is comfortable and appropriately positioned for the echocardiogram.
 Nurses should maintain a patient-centered approach, providing emotional support,
reassurance, and clear communication throughout the procedure.
Results: The images and data collected during the echocardiogram are sent for
interpretation by a cardiologist. The nurse may inform the patient about when they can
expect to receive the results.

63. AND OTHER TYPES OF DIAGNOSTIC
EXAM INCLUDES :
• BLOOD TESTS
• Hemodynamic Monitoring
• Arterial Blood Gas Analysis:
• Coronary Angiography
• Additional Imaging Studies
• Invasive Procedures

64. Incidence of Cardiogenic Shock Hospitalization and In‐Hospital
Mortality in the United States
INCIDENCE RATE
INTERNATIONAL

65. Figure 1. Prevalence of CS among hospitalizations during the study period.
AMI‐CS indicates acute myocardial infarction cardiogenic shock; CS,
cardiogenic shock; and non–AMI‐CS, non–acute myocardial infarction
cardiogenic shock.
Among a total of 563 949 644 hospitalizations during the period from
January 1, 2004, to December 30, 2018, 1 254 358 (0.2%) were attributed to
CS. There has been a steady increase in hospitalizations attributed to CS from
122 per 100 000 hospitalizations in 2004 to 408 per 100 000 hospitalizations
in 2018 (Ptrend<0.001). This increase was observed among AMI‐CS (from 44
per 100 000 hospitalizations in 2004 to 103 per 100 000 hospitalizations in
2018) and non–AMI‐CS (from 68 per 100 000 hospitalizations in 2004 to 258
per 100 000 hospitalizations in 2018) (Figure 1).

66. Figure 2. Trends in in‐hospital mortality among
patients with CS during the study period. A,
Unadjusted trends. B, Adjusted trends. AMI‐CS
indicates acute myocardial infarction cardiogenic
shock; CS, cardiogenic shock; and non–AMI‐CS, non–
acute myocardial infarction cardiogenic shock.
This was accompanied by a decline in in‐hospital
mortality during the study periods from 49% in 2004
to 37% in 2018 (Ptrend<0.001). The reduction in
in‐hospital mortality was seen among both patients
with AMI‐CS (from 44% in 2004 to 35% in
2018; Ptrend<0.001) and non–AMI‐CS (from 53% in
2004 to 36% in 2018; Ptrend<0.001). The results
remained significant even after the adjustment for
covariates with the overall in‐hospital mortality
improving from 49% in 2004 to 37% in 2018
(Ptrend<0.001), AMI‐CS improving from 43% in 2004
to 34% in 2018 (Ptrend<0.001), and non–AMI‐CS
improving from 52% in 2004 to 37% in 2018
(Ptrend<0.001) (Figure 2).

67. Figure 3. Trends in in‐hospital mortality
among patients with cardiogenic shock
during the study period stratified by sex. A,
Unadjusted trends. B, Adjusted trends.
In the unadjusted analysis, a consistent
reduction of in‐hospital mortality was seen
among men (from 47% in 2004 to 35% in
2018; Ptrend<0.001) and women (from 51%
in 2004 to 40% in 2018; Ptrend<0.001)
(Figure 3).

68. Figure 4. Trends in in‐hospital
mortality among patients with
cardiogenic shock during the study
period stratified by race/ethnicity. A,
Unadjusted trends. B, Adjusted trends.
Furthermore, the trends showed a
consistent reduction in in‐hospital
mortality among White patients (from
50% in 2004 to 37% in
2018; Ptrend<0.001), Black patients (from
49% in 2004 to 36% in
2018; Ptrend<0.001), Hispanic patients
(from 49% in 2004 to 35% in
2018; Ptrend<0.001), and Asian or Pacific
Islander patients (from 54% in 2004 to
39% in 2018; Ptrend<0.001) (Figure 4.)

69. DISCUSSION
In this contemporary observational study using a nationally
representative sample of the US population, we report several
significant findings. First, CS hospitalizations have almost tripled
during the study period. Second, we report a decreasing trend in
in‐hospital mortality among patients admitted with CS. Third, the
decreasing trends of in‐hospital mortality were consistent across all
subgroups analyzed, including men and women, AMI‐CS and
non‐AMI CS, and across different racial/ethnic groups. Fourth, there
was a decreasing temporal trend in CS in‐hospital mortality across all
US regions and regardless of hospital size or teaching status.

70. This is the most extensive study using a nationally representative sample of
the US population to analyze the temporal trends in CS hospitalization
incidence and in‐hospital mortality. Prior investigations of temporal trends in
CS morality were limited to registry data contributed by few select hospitals
and do not necessarily reflect the national trends in incidence of outcomes of
CS. Our findings corroborate and expand on the results from prior
single‐center studies, multicenter studies, and registries. In a large registry
spanning >20 years from Switzerland, the authors reported an increase in CS
admission among patients with AMI‐CS in the period from 1997 to 2017 by
more than double from 2.5% to 4.6%. Similarly, in a recent retrospective report
from the Mayo Clinic cardiac intensive care unit, which included >12 000
patients, the authors reported an increase in CS incidence by almost 4‐fold
from 5.7% in 2007 to 2009 to 19.4% in 2016 to 2018.
DISCUSSION

71. We postulate that the observed rise in CS hospitalizations is attributed to several factors.
There has been an increasing awareness about the importance of the appropriate and timely
diagnosis of CS and the inception of shock teams and shock algorithms; these may have
collectively led to the recognition of more patients with CS compared with the early years.
Moreover, studies have suggested a shift in the epidemiological risk factors of cardiovascular
disease with a higher burden of classical risk factors such as obesity, diabetes mellitus, and
hypertension; all are also linked to coronary artery disease and heart failure, which are the
major etiologies of CS.
DISCUSSION
Consistent with previous studies, we report a decline in CS in‐hospital mortality during the
study period. A reduction in in‐hospital mortality was seen in the early years of the study
(2004–2008) and among the AMI‐CS and non–AMI‐CS cohorts. It is important to note that
there have been no changes in the administrative coding algorithms used to identify
patients with CS during this period. The adoption of early revascularization and the
proliferation of cardiac catheterization laboratories contributed to the early drop in
mortality among the AMI‐CS cohort.

72. For the non‐AMI cohort, the reduction in in‐hospital mortality during the early years
can be explained by the increased awareness about the importance of early diagnosis
of CS, advances in critical care management, and the proliferation of cardiac intensive
care units.
DISCUSSION
In addition, more robust contemporary percutaneous MCS platforms were
introduced into the US market between 2006 and 2008, which coincides with a major
drop in CS‐related mortality among the AMI and non‐AMI cohorts (Figure 2). Although
these devices have not been shown to improve survival in randomized clinical trials
independently, there has been increasing evidence supporting the implementation of
CS treatment algorithms that promote early diagnosis, early revascularization when
appropriate, use of invasive hemodynamic data, and early deployment of MCS. Further
refinements in CS treatment strategies, including shock teams and care algorithms, and
collaborative efforts such as the NCSI (National Cardiogenic Shock Initiative) may be
responsible for more recent reductions in CS mortality.

73. Our findings contrast to the conclusions of the study
by Wayangankar et al, who reported an increasing trend of in‐hospital
mortality among patients with CS during the period from 2005 to
2013. However, significant differences between the 2 studies need to
be noted. First, Wayangankar et al used the NCDR (National
Cardiovascular Data Registry CathPCI Registry), in contrast to the NIS
used in the current study. Second, Wayangankar et al only included
patients with AMI‐CS who were treated with percutaneous coronary
intervention. Third, Wayangankar et al excluded patients who had
symptoms for >24 hours (n=17 791).
DISCUSSION

74. It is important to note that the only randomized trial to date that has shown
a reduction in mortality among patients with CS is the SHOCK (Should We
Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial,
which showed that compared with medical stabilization alone, emergency
revascularization was associated with a significant reduction in mortality. On the
other hand, although randomized clinical trials on MCS did not show a mortality
benefit, these trials had several limitations and enrolled the patients who were
sickest in whom shock had progressed from a reversible hemodynamic phase to
an irreversible hemometabolic phase. Recognition of this fact led multiple
investigators to develop a CS treatment algorithm aimed at early recognition of
CS, early revascularization, early use of invasive hemodynamic monitoring, and
early deployment of MCS.
DISCUSSION

75. After the encouraging results of incorporating the CS treatment algorithm in
the Detroit Cardiogenic Shock Initiative in which the investigators could reduce
in‐hospital mortality to 24%, a similar treatment algorithm has been adopted
at the national level under the currently active NCSI. Early reports from the
NCSI indicate a reduction in mortality to 28% in patients with AMI‐CS. The
mortality benefit of implementing a bundled approach with shock teams, early
invasive hemodynamic monitoring, and early MCS need confirmation in
randomized controlled trials. Despite the strategies mentioned previously,
mortality among patients with CS continues to be substantial, thereby
prompting further research to improve CS outcomes.
DISCUSSION

76. Prevention
 Don't smoke, and avoid secondhand smoke. If you smoke, the best way to
reduce your heart attack risk is to quit.
 Maintain a healthy weight. Being overweight contributes to other risk
factors for heart attack and cardiogenic shock, such as high blood
pressure, cardiovascular disease and diabetes. Losing just 10 pounds (4.5
kilograms) can lower blood pressure and improve cholesterol levels.
 Eat less cholesterol and saturated fat. Limiting these, especially saturated
fat, can reduce your risk of heart disease. Avoid trans fats.
 Use less salt. Too much salt (sodium) leads to fluid buildup in the body,
which can strain the heart. Aim for less than 2,300 milligrams (mg) a day of
sodium. Salt can be found in many canned and processed goods, so it's a
good idea to check food labels.

77.  Cut back on sugar. This will help you avoid nutrient-poor calories and
help you maintain a healthy weight.
 Limit alcohol. If you choose to drink alcohol, do so in moderation. For
healthy adults, that means up to one drink a day for women and up to
two drinks a day for men.
 Exercise regularly. Exercise can lower your blood pressure and improve
the overall health of your blood vessels and heart. Get at least 150
minutes of moderate aerobic activity or 75 minutes of vigorous aerobic
activity a week, or a combination of moderate and vigorous activity. It's
recommended to spread out this exercise during the course of a week.
Greater amounts of exercise will provide even greater health benefits.
Prevention

78. PROGNOSIS
The prognosis of cardiogenic shock can
vary widely depending on several factors,
including the underlying cause, the patient's
overall health, and the timeliness and
effectiveness of medical intervention.
Cardiogenic shock is a severe condition
characterized by inadequate blood flow to
meet the body's demands due to a failing
heart. The most common underlying cause
is a heart attack (myocardial infarction), but
other causes can include severe heart
failure, arrhythmias, valvular heart disease,
and other cardiac conditions.

79. Prognostic factors that can influence the outcome of cardiogenic shock include:
 Underlying Cause: The cause of cardiogenic shock plays a significant role in the prognosis.
Patients with cardiogenic shock due to a reversible cause, such as a treatable arrhythmia or a
partially blocked coronary artery, may have a better prognosis than those with extensive heart
damage.
 Timely Treatment: Early recognition and prompt treatment are crucial for improving the
prognosis. Patients who receive timely interventions, such as revascularization in the case of a
heart attack, have a better chance of survival and recovery.
 Age and Overall Health: Younger, healthier patients often have a better prognosis than older
individuals or those with multiple comorbidities.
 Extent of Myocardial Damage: The amount of heart muscle damage is a significant determinant
of prognosis. Patients with larger areas of damaged myocardium may face a more challenging
recovery.
 Response to Treatment: How well a patient responds to initial treatments, such as medications,
mechanical support devices, and interventions, can influence the outcome.
 Complications: The development of complications, such as multi-organ failure, can worsen the
prognosis.

80.  Quality of Cardiac Care: Access to specialized cardiac care facilities and experienced
healthcare providers can improve the prognosis.
It's important to note that cardiogenic shock is a life-threatening condition with a high
mortality rate. Even with optimal care, the prognosis can be guarded. The goal of treatment is to
stabilize the patient, restore cardiac function, and address the underlying cause. In some cases,
patients may require mechanical circulatory support, such as an intra-aortic balloon pump or
extracorporeal membrane oxygenation (ECMO), to maintain vital organ perfusion while the heart
recovers.
Overall, the prognosis of cardiogenic shock is best assessed on an individual basis, considering
the specific circumstances and characteristics of the patient. Early recognition, swift intervention,
and comprehensive critical care are essential in improving the chances of a favorable outcome.
PROGNOSIS

81. THANK YOU
for
LISTENING
and
God Bless 81