What is the treatment for cardiogenic shock in the pre-hospital (out-of-hospital) setting?

From the Guidelines

Pre-hospital treatment of cardiogenic shock should focus on rapid identification, stabilization, and transport to a facility capable of definitive interventions, with initial management including securing the airway, providing supplemental oxygen, and establishing IV access for medication administration, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.

Key Components of Pre-Hospital Care

• Securing the airway and providing supplemental oxygen to maintain saturation above 94%
• Establishing IV access for medication administration
• Fluid resuscitation with small boluses (250-500mL) while monitoring for pulmonary edema
• Use of vasopressors and inotropes, with norepinephrine as the first-line vasopressor and dobutamine for inotropic support
• Continuous cardiac monitoring to detect and treat arrhythmias
• Pain management with morphine to reduce sympathetic drive and cardiac workload

Goal of Pre-Hospital Care

• Maintain a systolic blood pressure of at least 90mmHg to ensure organ perfusion
• Arrange rapid transport to a facility capable of definitive interventions such as percutaneous coronary intervention, mechanical circulatory support, or advanced heart failure therapies

Importance of Team-Based Care

• Team-based cardiogenic shock management provides the opportunity for various clinicians to provide their perspective and input to the patient’s management, as highlighted in the 2022 AHA/ACC/HFSA guideline 1
• Escalation of pharmacological and mechanical therapies should be considered in the context of multidisciplinary teams of HF and critical care specialists, interventional cardiologists, and cardiac surgeons

Use of Mechanical Circulatory Support

• Short-term mechanical circulatory support may be considered in refractory cardiogenic shock, depending on patient age, comorbidities, and neurological function, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1
• The choice of specific mechanical circulatory support device should be guided by invasively obtained hemodynamic data and the patient's overall prognosis and trajectory, as suggested by the 2022 AHA/ACC/HFSA guideline 1

From the FDA Drug Label

To maintain systemic blood pressure during the management of cardiac arrest, LEVOPHED is used in the same manner as described under Restoration of Blood Pressure in Acute Hypotensive States. The infusion should be continued until adequate blood pressure and tissue perfusion are maintained without therapy. In some of the reported cases of vascular collapse due to acute myocardial infarction, treatment was required for up to six days.

The treatment of cardiogenic shock in pre-hospital settings may involve the use of norepinephrine (IV) 2 to restore and maintain adequate blood pressure. The average dosage is 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, and the maintenance dose ranges from 0.5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base). Key considerations for treatment include:

• Monitoring blood pressure frequently
• Titration to avoid excessive increases in blood pressure
• Potential for cardiac arrhythmias and ischemia
• Risk of extravasation and tissue necrosis with intravenous infusion
• Monitoring for signs of renal impairment
• Potential for allergic reactions associated with sulfite in epinephrine 3.

From the Research

Treatment of Cardiogenic Shock in Pre-Hospital Setting

• The treatment of cardiogenic shock in the pre-hospital setting is crucial for improving patient outcomes 4.
• Experts recommend a multidisciplinary approach to managing cardiogenic shock, including prehospital care, cardiac arrest management, and mechanical assistance 4.
• The use of vasoactive drugs, such as norepinephrine and dobutamine, may be considered in the pre-hospital setting, but their effectiveness is limited by scarce data and potential side effects 5.
• Crystalloids, such as lactated Ringer's or Plasma-Lyte, may be used for fluid resuscitation in the pre-hospital setting, but their effectiveness compared to colloids is uncertain 6.

Fluid Resuscitation

• Crystalloids are commonly used for fluid resuscitation in the pre-hospital setting, but their use may be limited by their inability to stabilize resuscitation endpoints 6.
• Balanced crystalloid solutions, such as lactated Ringer's or Plasma-Lyte, may be preferred over saline due to their more physiologic composition and potential to reduce complications 7.
• The choice of fluid for resuscitation should be guided by the patient's individual needs and the availability of resources in the pre-hospital setting.

Vasoactive Drugs

• Norepinephrine may be preferred over epinephrine for the treatment of cardiogenic shock due to its potential to improve outcomes 5.
• Dobutamine may be used as a first-line inotrope agent, while levosimendan may be considered as a second-line agent or in patients previously treated with beta-blockers 5.
• The use of vasoactive drugs should be guided by the patient's individual needs and the availability of resources in the pre-hospital setting.