What is the pre-hospital management of cardiogenic shock (cardiac output dysfunction)?

From the Guidelines

Pre-hospital management of cardiogenic shock should prioritize rapid recognition, intervention, and transport to a facility capable of definitive care, with a focus on maintaining adequate tissue perfusion, optimizing cardiac function, and arranging for advanced cardiac capabilities, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The primary goals of pre-hospital management include:

• Maintaining adequate tissue perfusion
• Optimizing cardiac function
• Arranging rapid transport to a facility capable of definitive care Initial assessment should focus on identifying signs of shock, including:
• Hypotension (systolic BP <90 mmHg)
• Altered mental status
• Cool extremities
• Decreased urine output
• Tachycardia Oxygen should be administered immediately to maintain saturation >94%, with intubation considered for respiratory distress or altered mental status. Establish two large-bore IV lines for medication administration and fluid resuscitation, with fluid challenges of 250-500 mL normal saline given cautiously to avoid worsening pulmonary edema. Vasopressors and inotropes are often necessary, with norepinephrine (starting at 0.1-0.5 mcg/kg/min) being the first-line vasopressor for hypotension, while dobutamine (2-20 mcg/kg/min) can improve cardiac output, as suggested by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. For patients with acute coronary syndrome causing cardiogenic shock, aspirin (325 mg chewed) should be administered, and a 12-lead ECG obtained to identify STEMI, with pain control using morphine (2-4 mg IV) considered if appropriate. Continuous cardiac monitoring is essential to detect and treat life-threatening arrhythmias, with pre-hospital notification to the receiving facility crucial to activate cardiac catheterization teams if STEMI is identified. Transport should be expedited to facilities with advanced cardiac capabilities, including mechanical circulatory support options like intra-aortic balloon pumps or ECMO, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Pre-Hospital Management of Cardiogenic Shock

• The management of cardiogenic shock remains largely driven by expert consensus due to limited evidence from randomized controlled trials 2.
• Early recognition and treatment of cardiogenic shock are crucial, including early revascularization of the culprit lesion with possible staged revascularization in acute myocardial infarction (AMI)-CS 2, 3.
• Optimal volume management and vasoactive drugs titrated to restore arterial pressure and perfusion are the cornerstone of cardiogenic shock therapy 2, 3.
• The choice of vasoactive drugs depends on the underlying cause and phenotype of cardiogenic shock, and their use should be limited to the shortest duration and lowest possible dose 2.

Diagnosis and Identification

• Cardiogenic shock is difficult to diagnose due to diverse presentations, overlap with other shock states, poorly understood pathophysiology, complex and multifactorial causes, and varied hemodynamic parameters 4.
• The diagnosis of cardiogenic shock can be made in the emergency department by clinical evaluation, diagnostic studies, and ultrasound 4.
• Early recognition and stabilization improve morbidity and mortality, and emergency clinicians should use clinical examination, laboratory studies, electrocardiogram, and point-of-care ultrasound to aid in the identification of cardiogenic shock 4.

Treatment Approach

• A structured ABCDE approach involving stabilization of the airway, breathing, and circulation, followed by damage control and etiologic assessment, is recommended for managing cardiogenic shock 3.
• Norepinephrine is titrated to restore mean arterial pressure, and dobutamine is titrated to restore cardiac output and organ perfusion 3.
• Echocardiography is essential to identify potential causes and characterize the phenotype of cardiogenic shock, and coronary angiography is usually indicated, particularly when acute myocardial ischemia is suspected 3.
• An invasive hemodynamic assessment can clarify whether temporary mechanical circulatory support is necessary, and early stabilization of hemodynamics and end-organ function is necessary to achieve best outcomes in cardiogenic shock 2, 3.