Cardiogenic Shock & Tamponade

Cardiogenic shock = SBP <90 + hypoperfusion (cold, oliguria, lactate) from pump failure — usually post-MI. Echo answers everything: LV function, mechanical complications (VSR, papillary rupture), tamponade (Beck's triad, RV collapse →…

Pump Failure Pathway

The pathway

1 · Recognise cold + wet

SBP <90, cold peripheries, UO <0.5ml/kg/hr, lactate >2, confusion
Crackles = congestion → not simple hypovolaemia

2 · ECG immediately

Re-occlusion/stent thrombosis?
New arrhythmia — treat per ALS
Compare with previous

3 · Urgent bedside echo

LV function
Mechanical complications: VSR, papillary rupture (new murmur!)
Effusion/tamponade: RV diastolic collapse

4 · Call cardiology + ITU

Level 2/3 care, invasive monitoring
Revascularisation discussion if ischaemic driver
Shock-centre/mechanical support conversation early

5 · Tamponade = needle

Beck's triad + pulsus paradoxus
Emergency echo-guided pericardiocentesis
Fluids temporise (preload-dependent)

6 · Avoid harm

No reflex fluid loads (250ml test only if dry)
No beta-blockers in acute shock
Cautious opioids/nitrates — they drop preload

Drugs

Drug	Dose	Route	Notes
Noradrenaline	Titrated (ITU)	IV central	Restores perfusion pressure — ITU only.
Dobutamine	2.5–10mcg/kg/min (ITU)	IV	Inotropy for low-output state.
Furosemide	40–80mg IV	IV	Only for congestion WITH adequate BP — not in profound hypotension.
AVOID: beta-blockers	—	—	Contraindicated in acute cardiogenic shock.

When to escalate

Cold + oliguric + lactate — cardiology + ITU now, before arrest,New murmur post-MI — mechanical complication: echo + surgeons,Beck's triad post-procedure — pericardiocentesis, crash call,Rising lactate/falling UO despite support — mechanical support discussion

Reference: ESC ACS Guidelines 2023 / Resus Council ALS (tamponade — 4Ts)

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