**8. Obstructive shock**

Document reassessment of volume status and tissue perfusion with either:

nary examination, and skin findings.

Or any two of the following:

34 Essentials of Accident and Emergency Medicine

**7. Cardiogenic shock**

. • Bedside cardiovascular ultrasound.

Management of cardiogenic shock includes:

(5μg/kg/min).

mortality rate [1].

**3.** Treating arrhythmias.

**4.** Aspirin and heparin (if indicated).

• Measure CVP.

• Measure ScvO<sup>2</sup>

• Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmo-

• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge [5].

Cardiogenic shock results when more than 40% of the myocardium is damaged by necrosis from ischemia, inflammation, and toxins. There is decreased cardiac output due to pump failure such as cardiomyopathy, myocardial infarction, valvular insufficiency, and arrhythmias. This shock can further persist and eventually lead to cardiac arrest. Usually patients in cardiogenic shock look ill, drowsy, sweaty, and pale and can have tachycardia with weak pulse and hypotensive. The urine output would be deceased to less than 0.5 ml/kg/h, and serum lactic acid would be as high as 4 mmol/L, indicating circulatory insufficiency. Left ventricular dysfunction can be detected by echo early in the course of cardiogenic shock. Patients with severe left ventricle dysfunction are more liable to develop shock than those with mild to moderate dysfunction. Serial cardiac markers and bedside echo for such cases are worth doing as they can aid in diagnosis and effective management. Patient needs to be monitored closely and vital signs recorded frequently. It is worth to have an arterial line in place for accurate blood pressure readings. Monitoring urine output, base deficit, and serum lactic acid is important

for the assessment of resuscitation in all patients who are in shock [4] (**Figure 5**).

**1.** Improve the work of breathing by adequate oxygenation and ventilation.

**2.** Initiation of vasopressors or inotropes, e.g., norepinephrine (0.5 μg/min or dobutamine

**5.** Treatment of the cause, e.g., thrombolysis or angioplasty (e.g., myocardial infarction). In

Emergency reperfusion procedure (thrombolysis/PTCA) is not superior to medical management in cardiogenic shock, secondary to myocardial infarction. There is no reduction in the

refractory cases of cardiogenic shock, intra-aortic balloon pump can be used.

It is usually due to extra cardiac etiologies which result in poor right ventricle output. Causes are:


Bedside ultrasound would be of absolute benefit in diagnosing obstructive shock [2].
