Shock

Rule out tamponade.
Assess for signs of fluid responsiveness. Give fluid if appropriate. Be aware that ventricular failure may result in false positives when using respiratory changes in haemodynamics.
If not fluid responsive assess for ventricular failure.
No failure – use vasopressors.
LV failure – use inotropes
RV failure – use vasopressors, consider lowering PVR, consider inotropes.
Biventricular failure – use inotropes.

Acute circulatory failure and pulmonary oedema (elevated LV filling pressures)

No LV systolic dysfunction – LV volume overload (acute severe regurg, volume overload).
LV systolic dysfunction – AMI (extensive, extended, complications), non ischaemic cardiomyopathy, myocarditis, contusion, drugs. A septic cardiomyopathy will have variable LV filling pressures depending on fluid resuscitation.

Acute circulatory failure and elevated RV filling pressures

Tamponade
RV dysfunction/dilatation

  • Pulmonary hypertension
  • No – RV infarct – often associated LV inferior wall abnormality.

Chronic pulmonary hypertension shown by severe RV free wall hypertrophy (>10mm) and severe pulmonary hypertension. If acute the pulmonary hypertension is less severe.

Monitoring failed therapy

Development of LV failure secondary to increased afterload from vasopressors.
Dynamic LVOT obstruction exacerbated by inotropes.
Adrenergic induced LV RWMA.
Inappropriate ventilator settings.

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