A state of inadequate tissue perfusion primarily due to cardiac dysfunction.
It may occur suddenly, or after progressively worsening heart failure.

Management

If the cause is myocardial infarction prompt reperfusion therapy is vital If BP unrecordable, call the cardiac arrest team.

• Manage in Coronary Care Unit, or ICU.

Investigations

• ECG
• Urea & Creatinine
• Electrolyte
• Troponin
• ABG
• CXR
• Echo
• If indicated, CT thorax
  • Speak with radiologists, this can be protocolled for both aortic dissection and PE.

Monitor

• CVP and an arterial line to monitor pressure
  • If these are already in place consider measuring cardiac output and volume status
• BP
• ABG
• ECG
  • Record a 12-lead ECG every hour until the diagnosis is made.
  • Keep on cardiac monitor.
• Urine output.
  • Catheterize for accurate urine output.

Treatment

• Oxygen target arterial saturations of 94–98% (88–92% if COPD)
• Diamorphine 1.25–5mg IV for pain and anxiety
• Investigations and close monitoring: see above
• Correct:
  • Arrhythmias
  • Urea, Creatinine, & Electrolytes abnormalities
  • Acid–base disturbance
• Optimize filling pressure with clinical assessment of pulse, BP, JVP/CVP
• If underfilled:
  • Give a plasma expander 100mL every 15min IV
  • Aim MAP 70mmHg, CVP 8–10mmHg
• If well/over-filled:
  • Inotropic support, e.g. dobutamine 2.5–10mcg/kg/min IVI.
  • Aim MAP 70mmHg
• Look for and treat any reversible cause
  • MI or PE : consider thrombolysis
  • Surgery for: acute VSD, mitral, or aortic incompetence