Red flags
- Lactate >4 rising despite therapy
- Multiorgan failure onset
- Refractory hypotension on 2 vasopressors
- Mechanical complication (VSR, MR, tamponade)
First steps
- ABCDE + arterial + central line
- Norad first (target MAP ≥65)
- Add dobutamine or milrinone for inotropy (milrinone if on β-blocker)
- Bedside echo urgently
Key investigations
- Serial lactate
- Echo (LV, RV, valves, tamponade, wall motion)
- ECG, troponin, BNP
- Coronary angiography if ACS
- SvO2/PAC if refractory
Differentials
- Distributive shock (septic mixed)
- Obstructive (PE, tamponade, tension pneumo)
- Hypovolaemic (bleeding)
Initial management
- Early PCI (culprit-only per CULPRIT-SHOCK)
- Mechanical circulatory support: IABP (limited), Impella, VA-ECMO
- Correct mechanical complications surgically
- Treat arrhythmia
Referral
- Cardiogenic shock centre with MCS if refractory
- CT surgery for mechanical complications
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