Synopsis
Recognise tissue hypoperfusion from cardiac failure, separate LV, RV and mechanical phenotypes and restore the cause and perfusion without delaying definitive intervention.
- Shock is inadequate tissue perfusion, not a blood-pressure number alone: look for altered mentation, cool/mottled skin, oliguria, narrow pulse pressure, rising lactate and metabolic acidosis.
- Common causes are acute MI, decompensated HFrEF, fulminant myocarditis, severe tachy/bradyarrhythmia, acute valve or post-MI mechanical complication and acute RV failure.
- Bedside echo must rapidly distinguish LV failure, RV failure, tamponade, acute MR, VSD and major valve disease; a single estimated EF does not define the whole shock state.
Key red flags
Confusion, agitation, cool mottled extremities, weak pulse, oliguria and rising lactate can precede severe hypotension.
Investigation priorities
Detect STEMI/NSTE-ACS, arrhythmia or conduction disease.
Management branches
Suspected cardiogenic shock
- Start ABCDE, high-acuity monitoring, arterial blood gas/lactate, ECG, IV access and targeted oxygen/ventilation; call cardiology and critical care immediately.
- Obtain urgent bedside echo and look for ACS, arrhythmia, tamponade, acute MR/VSD, RV failure, PE, bleeding or sepsis.
Key medicines
NoradrenalineThe cited ready-to-use SmPC, licensed for adults weighing over 50 kg, starts noradrenaline base at 0.05–0.15 micrograms/kg/min by central IV infusion pump, titrated in 0.05–0.1 micrograms/kg/min steps to perfusion/MAP; its maintenance range is 0.05–1.5 micrograms/kg/min.
DobutamineUsually 2.5–10 micrograms/kg/min by continuous IV infusion, titrated to output and perfusion; higher doses are exceptional.