Box 67 Interventions in cardiogenic shock

• Reversible causes of pump failure - correct mechanical problems, heart rate, hypoxaemia, drug effects and hypocalcaemia

• Reversible ischaemia - thrombolysis is a priority if indicated. Anti platelet agents should be given. Other interventions may be indicated as directed by a cardiologist

• Suboptimal preload - assess volume status using fluid challenges and achieve effective circulating volume

• Haemodynamic data required - CVP line, urinary catheter, arterial line, (cardiac output measurements)

• Low cardiac output despite optimum heart rate and filling pressures - start dobutamine. If hypoperfusion still present at optimum doses, add a drug with a effects. Intra-aortic balloon pumping may also be used

Identify and treat patients in the preshock state early and effectively instead of waiting to take action once shock is established. When acidosis from hypoperfusion occurs, myocardial function is further depressed, vasoactive drugs are less likely to work, and it may be difficult to break the physiological downward spiral. Patients treated early but who fail to respond to optimum therapy are unlikely to have any significant cardiac reserve and have a poor prognosis.

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