CARDIOLOGY

ResponseCauses of cardiogenic shock  

• ACS (Reinfarction)  
• Arrhythmia: drop in LVEF/CO if AF new  
• Mechanical:  
• Pericardial tamponade (CABG dehiscence, Dressler’s syndrome)  
• Acute MV prolapse (papillary muscle rupture)  
• Ventricular septal rupture  
• LV aneurysm/rupture  
• Acute AR  
• Medication error (e.g B-blocker) 

Non cardiogenic causes 

• Massive PE  
• Hypovolaemia/severe anaemia (mediastinal/GIT/retroperitoneal bleeding. Post op and anticoagulated)  
• Sepsis/LRTI (hospital/ventilator acquired, surgical complication)  
• iv. Tension pneumothorax (although unlikely this late) 

ResponseMANAGEMENT
Careful fluid boluses 5 mls/kg IV NaCl 0.9%
Inotropes
i. Dobutamine 5 mcg/kg/min IVI
ii. Adrenaline 0.04 mcg/kg/min
iii. Accept other reasonable choices
Mechanical - IABP via PCI (Intraaortic balloon pump)

DISPOSITION
Provided no surgical intervention immediately indicated, cardiogenic shock should be investigated by PCI in case of acute coronary occlusion
Initial transfer to cardiac catheterisation lab in discussion with senior cardiologist
IABP decreases mortality in cardiogenic shock. If medical refractory to medical resuscitation, IABP placement is indicated.
Ultimate disposition is CCU, or ICU if other organ system support required

ENDPOINTS
SBP =/> 100mmHg
MAP =/> 70mmHg
Urine output >0.5ml/kg/hr
Normalisation of mentation if abnormal
Normalisation of lactate if abnormal