Severe Heart Failure & Cardiogenic Shock - Management Checklist Evaluation - EKG & echocardiography - CBC, Lytes including Ca/Mg/Phos - Troponin, Lactate, Liver function tests if shock is suspected - TSH and/or digoxin level depending on context Rx 1 — Treat the lungs - Consider BiPAP (vS intubation) in cardiogenic pulmonary edema - Large effusion(s) may be drained if causing acute distress - Consider inhaled epoprostenol for intubated patient with right ventricular failure or pulmonary hypertension Rx 2 — Optimize the MAP - HTN/normotension Afterload reduction (nitroglycerine infusion or hydralazine 37.5 mg & isosorbide dinitrate 20 mg q6hr) - Hypotension (severe or w/ organ dysfunction) Norepinephrine (epinephrine is another option in HFrEF with hypoperfusion) Rx 3 — Optimize the volume - Fluid challenge if: hypoperfusion, no pulmonary congestion (no B-lines on ultrasound), assessment suggests total body hypovolemia - Diuresis if: significant systemic/pulmonary congestion, assessment suggests total body volume overload Rx 4 — Consider inotrope (usually dobutamine/milrinone) for HFrEF if: - (a) Normotensive patient with organ hypoperfusion - (b) Refractory cardiogenic pulmonary edema in hypotensive patient - Note: Digoxin may be considered a weak inotropic agent in patients With chronic AF, HFrEF, and refractory heart failure. Rx 5 — Treat underlying etiology - New-onset tachyarrhythmia causing heart failure: cardioversion, antiarrhythmics - Ischemic cardiomyopathy: Revascularization, treatment for acute MI if present Rx 6 — Mechanical circulatory support - Consider for persistent Organ failure — device Of choice is patient/institution specific. Rx 7 — Things to avoid - Nephrotoxins (e.g. NSAlDs, ACE-inhibitors, angiotensin receptor blockers) - Initiation of beta-blocker in decompensated heart failure - Any beta-blocker or calcium channel blocker (eg diltiazem) in a patient with cardiogenic shock #Checklist #CHF #Shock #Cardiogenic #HeartFailure #Cardiology #Management
