management of cardiogenic shock

Last reviewed 11/2021

• seek expert help
• admit to intensive care
• pain relief e.g. diamorphine 5mg im/iv
• anxiolytic e.g. prochlorperazine 12.5mg im/iv
• 60% oxygen - later guided by blood gases
• monitor: ECG; U+Es, blood gases; urine output via catheter; CVP; a 12 lead ECG is repeated every hour until a diagnosis is reached
• correct arrhythmias
• consider insertion of a Swan-Ganz catheter: the pulmonary wedge pressure should be maintained between 15-20 mmHg by a combination of fluid infusion, inotrope and vasodilator therapy (pulmonary oedema will develop if wedge pressure > 20 mmHg):
• inotropes e.g. dobutamine (2.5-10 mcg/kg/min iv) in order to maintain a systolic blood pressure of > 80 mmHg
• renal support e.g. dopamine (2-4 mcg/kg/min iv)
• mechanical assistance may be given to the heart e.g. an intraaortic balloon pump

Additionally:

• treat the underlying cause e.g. myocardial infarction
• if new systolic murmur then may indicate development of VSD or papillary muscle rupture - early surgical repair is recommended - management of pulmonary oedema and hypotension as above
• diuretics have no place in the acute management of cardiogenic shock - they may be used once the patient's cardiac output has improved (e.g. improved mental state and skin perfusion)