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Cardiogenic Shock; Resident Survival Guide
Overview
Causes
FIRE
Emergency Revascularization
Complete Diagnostic Approach
Diagnostic Criteria Cardiogenic Shock Acute Myocardial Infarction
Blood Pressure Maintenance
Hemodynamic Optimization
Do's
Don'ts

VisualWikitext

Latest revision as of 00:09, 6 May 2014

Overview

The clinical definition of cardiogenic shock includes decreased cardiac output with evidence of tissue hypoxia in the presence of adequate intravascular volume.^[1]

Causes

Life Threatening Causes

Cardiogenic shock is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Arrhythmic

Mechanical

Myopathic

Pharmacologic

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.^[2]

Boxes in red signify that an urgent management is needed.

Abbreviations: CBC, complete blood count; CI, cardiac index; CK-MB, creatine kinase MB isoform; CVP, central venous pressure; DC, differential count; ICU, intensive care unit; INR, international normalized ratio; LFT, liver function test; MAP, mean arterial pressure; PCWP, pulmonary capillary wedge pressure; PT, prothrombin time; PTT, partial prothrombin time; SaO2, arterial oxygen saturation; SBP, systolic blood pressure; ScvO2, central venous oxygen saturation; SvO2, mixed venous oxygen saturation; SMA-7, sequential multiple analysis-7.

Does the patient have cardinal findings that increase the pretest probability of cardiogenic shock?

❑ Evidence of end-organ hypoperfusion

❑ Altered mental status

❑ Cold extremities

❑ Cyanosis

❑ Oliguria (urine output <0.5 mL/kg/h)

❑ Sustained hypotension (≥30 min)

❑ SBP <90 mm Hg or

❑ MAP ↓ >30 mm Hg below baseline

❑ Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue hypoperfusion

YES

NO

Cardiogenic shock suspected
(click for details on criteria)

Proceed to
shock resident survival guide

Immediate steps

Initial management

❑ Oxygen ± ventilatory support

❑ ECG monitor

❑ Pulse oximeter

❑ Sphygmomanometer or arterial line

❑ Large-bore peripheral venous lines

❑ Central venous catheter

❑ Bladder catheterization

❑ Hold antihypertensive medications

❑ ± Correct tachy- or bradyarrhythmia

Initial workup

❑ Arterial blood gas

❑ CBC/DC/SMA-7/LFT/PT/PTT/INR

❑ Cardiac troponins, CK-MB

❑ BNP, NT-proBNP

❑ Lactate

❑ 12-Lead ECG

❑ Chest radiograph

❑ Echocardiography

Maintain adequate blood pressure
(click for details)

SBP <70 mm Hg:

❑ Norepinephrine

❑ Initial dose: 0.5–1.0 μg/min

❑ Maximum dose: 30–40 μg/min

❑ Titrate to SBP >90 mm Hg

SBP 70–100 mm Hg with symptoms:

❑ Dopamine

❑ Cardiac dose: 5.0–10 μg/kg/min

❑ Pressor dose: 10–20 μg/kg/min

❑ Maximum dose: 20–50 μg/kg/min

SBP 70–100 mm Hg w/o symptoms:

❑ Dobutamine

❑ Usual dose: 2.0–20 μg/kg/min

❑ Maximum dose: 40 μg/kg/min

❑ Avoid ↑ HR by >10% of baseline

SBP >100 mm Hg:

❑ Nitroglycerin

❑ Initial dose: 5.0 μg/min

❑ Titrate by 10–20 μg/min q 3–5 min

❑ Nitroprusside

❑ Initial dose: 0.3 μg/kg/min

❑ Usual dose: 3.0–5.0 μg/kg/min

❑ Maximum dose: 10 μg/kg/min

Acute coronary syndrome likely?
(click for details on criteria)

❑ New ischemic ECG changes

❑ Positive cTnT, cTnI, or CK-MB

❑ Anginal pain

YES

NO

Proceed to
Emergency Revascularization

❑ ICU admission

❑ Swan-Ganz catheter

❑ Cardiology consultation

Optimize hemodynamic status
(click for details)

Preload

Goal: PCWP 15–18 mm Hg, CVP 8–12 cm H₂O

❑ Fluid challenge protocol ("TROL")

❑ ± Correct pulmonary congestion

❑ Furosemide

❑ Usual dose: 40 mg slow IV injection

❑ May increase dose to 80 mg after 1 hour as needed

❑ Morphine

❑ Usual dose: 2–4 mg slow IV injection

❑ May repeat dose every 5–30 minutes as needed

Afterload

Goal: MAP >65 mm Hg, SVR 800–1200 dyn·s·cm⁻⁵

❑ If ↑ MAP & ↑ SVR:

❑ Taper vasopressor

❑ ± Vasodilator

❑ Nitroglycerin

❑ Initial dose: 5.0 μg/min

❑ Titrate by 10–20 μg/min q 3–5 min

❑ Nitroprusside

❑ Initial dose: 0.3 μg/kg/min

❑ Usual dose: 3.0–5.0 μg/kg/min

❑ Maximum dose: 10 μg/kg/min

❑ If ↓ MAP & ↓ SVR:

❑ Vasopressor

❑ Norepinephrine

❑ Initial dose: 0.5–1.0 μg/min

❑ Maximum dose: 30–40 μg/min

❑ Titrate to SBP >90 mm Hg

❑ Dopamine

❑ Cardiac dose: 5.0–10 μg/kg/min

❑ Pressor dose: 10–20 μg/kg/min

❑ Maximum dose: 20–50 μg/kg/min

❑ Phenylephrine

❑ Initial dose: 100–180 μg/min

❑ Maintenance dose: 40–60 μg/min

❑ ± Vasopressin

❑ Adjunctive therapy to norepinephrine or dopamine

❑ Usual dose: 0.01–0.03 U/min

❑ Maximum dose: 0.04 U/min

❑ If ↓ MAP & ↑ SVR:

❑ Continue vasopressor

❑ Optimize cardiac output with inotropic agent

Cardiac index

Goal: CI >2.2 L/min/m²

❑ Dobutamine

❑ Usual dose: 2.0–20 μg/kg/min

❑ Maximum dose: 40 μg/kg/min

❑ Avoid ↑ HR by >10% of baseline

❑ Milrinone

❑ Loading dose: 50 μg/kg (slowly over 10 minutes)

❑ Maintenance dose: 0.375–0.75 μg/kg/min

Evaluate perfusion and oxygenation

Endpoints:

❑ SaO2 >92%

❑ SvO2 >60%

❑ ScvO2 >70%

❑ Urine output >0.5 mL/kg/h

❑ Lactate <2.2 mM/L

❑ Hematocrit ≥30%

If hypoperfusion persists:
❑ Consider IABP, VAD, or ECMO if indicated

Proceed to
complete diagnostic approach

Emergency Revascularization **[Return to FIRE]**

Acute coronary syndrome
(click for details on criteria)

❑ New ischemic ECG changes

❑ New or presumably new ST elevation at the J point in two contiguous leads with the cutoff points:

❑ ≥0.1 mV in all leads other than leads V₂–V₃

❑ ≥0.15 mV in women in leads V₂–V₃

❑ ≥0.2 mV in men ≥40 years in leads V₂–V₃

❑ ≥0.25 mV in men <40 years in leads V₂–V₃

❑ New left bundle branch block

❑ QRS duration ≥120 ms

❑ Supraventricular rhythm

❑ Absence of WPW pattern

❑ Broad and notched or slurred R in I and V₅ or V₆

❑ Absence of Q wave in I and V₅ and V₆

❑ R peak times ≥60 ms in V₅ or V₆

❑ New or presumably new ST-segment–T wave changes

❑ Horizontal or down-sloping ST depression ≥0.05 mV in two contiguous leads

❑ T inversion ≥0.1 mV in two contiguous leads with prominent R wave or R/S ratio >1

❑ Positive cardiac biomarkers (cTnT, cTnI, or CK-MB)

❑ Anginal pain

*ST elevation in contiguous leads and location of MI and coronary occlusion*
ECG Leads with STE	Location of MI	Location of Coronary Occlusion
I, aVL	Lateral, Apical	Diagonal, Obtuse Marginal, Distal LAD
II, III, aVF	Inferior	PDA, Wraparound LAD
V₁, V₂	Septal	Proximal LAD, Septal Perforators
V₃, V₄	Anterior	Proximal or Mid LAD, Diagonal
V₅, V₆	Lateral, Apical	Diagonal, Obtuse Marginal, Distal LAD
V₇, V₈, V₉	Posterobasal	LCx, RCA
V₃R, V₄R	RV Free Wall	Proximal RCA

STEMI

UA/NSTEMI

Complete Diagnostic Approach **[Return to FIRE]**

Diagnostic Criteria **[Return to FIRE]**

Criteria for Cardiogenic Shock

Clinical Criteria^[1]^[3]^[4]

Sustained hypotension (SBP <90 mm Hg or MAP 30 mm Hg below baseline in preexisting hypertension for at least 30 minutes)
Evidence of tissue hypoperfusion (such as oliguria, cyanosis, cool extremities, and altered mental status)
Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue hypoperfusion (such as hypovolemia, hypoxia, and acidosis)

Hemodynamic Criteria^[1]^[4]^[5]^[6]^[7]

Sustained hypotension (SBP <90 mm Hg or MAP 30 mm Hg below baseline in preexisting hypertension for at least 30 minutes)
Depressed cardiac index (<1.8 L/min/m² of BSA without support or <2.0–2.2 L/min/m² of BSA with support) in the presence of an elevated wedge pressure (>15 mm Hg).

Criteria for Acute Myocardial Infarction

The term acute myocardial infarction (MI) should be used when there is evidence of myocardial necrosis in a clinical setting consistent with acute myocardial ischemia. Under these conditions any one of the following criteria meets the diagnosis for MI:

Detection of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin) with at least one value above the 99^th percentile upper reference limit (URL) and with at least one of the following:^[8]

Symptoms of ischemia^[9]^[10]^[11]

Recent episode of typical ischemic discomfort that either is of new onset or is severe or that exhibits an accelerating pattern of previous stable angina (especially if it has occurred at rest or is within 2 weeks of a previously documented MI)
Quality: squeezing, grip-like, pressure-like, suffocating, crushing, or heavy
Location: diffuse, not localized, nor positional, nor affected by movement at substernal area ± radiation to the neck, jaw, epigastrium, shoulders, or arms
Duration: usually >20 minutes
Factors that provoke the pain: exertion or emotional stress
Factors that relieve the pain: rest or sublingual nitroglycerin (usually within minutes)
Accompanying symptoms: diaphoresis, nausea or syncope

New or presumably new significant ST-segment–T wave changes or new left bundle branch block (LBBB).
Development of pathological Q waves in the ECG.
Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
Identification of an intracoronary thrombus by angiography or autopsy.

Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes or new LBBB, but death occurred before cardiac biomarkers were obtained, or before cardiac biomarker values would be increased.

Percutaneous coronary intervention related MI is arbitrarily defined by elevation of cardiac troponin (cTn) values (>5 × 99^th percentile URL) in patients with normal baseline values (≤99^th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, either one of the followings is required:

Symptoms suggestive of myocardial ischemia
New ischemic ECG changes
Angiographic findings consistent with a procedural complication
Imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality

Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac biomarker values with at least one value above the 99^th percentile URL.

Coronary artery bypass grafting related MI is arbitrarily defined by elevation of cardiac biomarker values (>10 × 99^th percentile URL) in patients with normal baseline cTn values (≤99^th percentile URL). In addition, either one of the followings is required:

New pathological Q waves or new LBBB
Angiographic documented new graft or new native coronary artery occlusion
Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality

Maintenance of Blood Pressure **[Return to FIRE]**

Norepinephrine

Dosage and Administration^[12]^[13]^[14]

Suggested Dilution:

Mix 4 mg of norepinephrine in 250 mL of D5W or D5NS. Avoid dilution in normal saline alone.

Suggested Regimen:

Start at a dose of 0.5–1.0 μg/min IV infusion; titrate to maintain SBP at above 90 mm Hg (up to 30–40 μg/min).

Contraindications

Norepinephrine should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed.
Norepinephrine should also not be given to patients with mesenteric or peripheral vascular thrombosis unless it is necessary as a life-saving procedure.

Dopamine

Dosage and Administration^[12]^[13]^[15]

Suggested Dilution: transfer contents of one or more ampuls or vials by aseptic technique to either 250 mL or 500 mL of one of the following sterile intravenous solutions

Sodium Chloride Injection
Dextrose (5%) Injection
Dextrose (5%) and Sodium Chloride (0.9%) Injection
5% Dextrose in 0.45% Sodium Chloride Solution
Dextrose (5%) in Lactated Ringer’s Solution
Sodium Lactate (1/6 Molar) Injection
Lactated Ringer’s Injection

Suggested Regimen:

Begin administration of diluted solution at doses of 2–5 μg/kg/minute in patients who are likely to respond to modest increments of heart force and renal perfusion.
In more seriously ill patients, begin administration of diluted solution at doses of 5 μg/kg/minute and increase gradually, using 5–10 μg/kg/minute increments, up to 20–50 μg/kg/minute as needed.
If doses of 50 μg/kg/minute are required, it is suggested that urine output be checked frequently. Should the urine flow begin to decrease in the absence of hypotension, reduction of dosage should be considered.
Treatment of all patients requires constant evaluation of therapy in terms of the blood volume, augmentation of myocardial contractility, and distribution of peripheral perfusion. Dosage should be adjusted according to the patient’s response, with particular attention to diminution of established urine flow rate, increasing tachycardia or development of new dysrhythmias as indices for decreasing or temporarily suspending the dosage.

Contraindications

Pheochromocytoma
Uncorrected tachyarrhythmias or ventricular fibrillation

Dobutamine

Dosage and Administration^[12]^[13]^[16]

Suggested Dilution: dobutamine injection must be further diluted in an IV container. Dilute 20 mL of dobutamine in at least 50 mL of diluent and dilute 40 mL of dobutamine in at least 100 mL of diluent. Use one of the following intravenous solutions as a diluent:

Dextrose Injection 5%
Dextrose 5% and Sodium Chloride 0.45% Injection
Dextrose 5% and Sodium Chloride 0.9% Injection
Dextrose Injection 10%, Isolyte® M with 5% Dextrose Injection
Lactated Ringer’s Injection
5% Dextrose in Lactated Ringer’s Injection
Normosol®-M in D5-W
20% Osmitrol® in Water for Injection
Sodium Chloride Injection 0.9%
Sodium Lactate Injection

Suggested Regimen:

The rate of infusion needed to increase cardiac output usually ranged from 2.5 to 15 mcg/kg/min.
On rare occasions, infusion rates up to 40 mcg/kg/min have been required to obtain the desired effect.

Contraindications

Idiopathic hypertrophic subaortic stenosis
Hypersensitivity to dobutamine

Nitroglycerin

Dosage and Administration^[12]^[13]^[17]

Suggested Initial Dilution:

Nitroglycerin must be diluted in dextrose (5%) injection or sodium chloride (0.9%) injection prior to its infusion. Transfer 50 mg of nitroglycerin into a 500 mL glass bottle of either dextrose (5%) injection or sodium chloride injection (0.9%). This yields a final concentration of 100 μg/mL. Diluting 5 mg nitroglycerin into 100 mL will yield a final concentration of 50 μg/mL.

Suggested Maintenance Dilution:

Consider the fluid requirements of the patient as well as the expected duration of infusion in selecting the appropriate dilution of Nitroglycerin Injection.
The concentration of nitroglycerin should not exceed 400 μg/mL.

Suggested Regimen:

Severe hypotension and shock may occur with even small doses of nitroglycerin. This drug should therefore be used with caution in patients who may be volume depleted or who, for whatever reason, are already hypotensive. Hypotension induced by nitroglycerin may be accompanied by paradoxical bradycardia and increased angina pectoris.
The initial dosage should be 5 μg/min delivered through an infusion pump. Subsequent titration must be adjusted to the clinical situation, with dose increments becoming more cautious as partial response is seen.
Initial titration should be in 5 μg/min increments, with increases every 3–5 minutes until some response is noted.
If no response is seen at 20 μg/min, increments of 10 and later 20 μg/min can be used.
Once a partial blood pressure response is observed, the dose increase should be reduced and the interval between increases should be lengthened.

Contraindications

Pericardial tamponade
Restrictive cardiomyopathy
Constrictive pericarditis
Hypersensitivity to nitroglycerin

Nitroprusside

Dosage and Administration^[12]^[13]^[18]^[19]

Suggested Dilution:

Depending on the desired concentration, the solution containing 50 mg of nitroprusside must be further diluted in 250–1000 mL of sterile 5% dextrose injection.

Suggested Regimen:

While the average effective rate in adult and pediatric patients is about 3 μg/kg/min, some patients will become dangerously hypotensive at this rate.
Nitroprusside can induce essentially unlimited blood pressure reduction, the blood pressure must be continuously monitored, using either a continually reinflated sphygmomanometer or (preferably) an intra-arterial pressure sensor. Special caution should be used in elderly patients, since they may be more sensitive to the hypotensive effects of the drug.
Infusion of sodium nitroprusside should be started at a very low rate (0.3 μg/kg/min), with upward titration every few minutes until the desired effect is achieved or the maximum recommended infusion rate (10 μg/kg/min) has been reached.

Contraindications

Sodium nitroprusside should not be used for the treatment of acute congestive heart failure associated with reduced peripheral vascular resistance such as high-output heart failure that may be seen in endotoxic sepsis.
Sodium nitroprusside should not be used in the treatment of compensatory hypertension, where the primary hemodynamic lesion is aortic coarctation or arteriovenous shunting.
Sodium nitroprusside should not be used to produce hypotension during surgery in patients with known inadequate cerebral circulation, or in moribund patients coming to emergency surgery.
Patients with congenital (Leber’s) optic atrophy or with toxic amblyopia have unusually high cyanide/thiocyanate ratios. These rare conditions are probably associated with defective or absent rhodanase, and sodium nitroprusside should be avoided in these patients.

Optimization of Hemodynamic Status **[Return to FIRE]**

Preload Optimization

Fluid Challenge Protocol

Preload optimization involves scrupulous fluid loading, manipulation of PCWP and/or CVP levels, and correction of pulmonary congestion.^[5]^[6]^[7]^[20]

Protocolized fluid administration titrated to hemodynamic and clinical endpoints secures the efficacy of tissue perfusion and oxygenation.^[21]

Four elements of the fluid challenge protocol: type of fluid (T), rate of fluid administration (R), objective (O), and limits (L).^[22]

1. Type of fluid (T)

The choice of crystalloid or colloid solution should be made on the basis of the underlying disease, the nature of fluid deficit, the severity of circulatory failure, the serum albumin concentration, and the risk of bleeding.^[23]
There were no significant differences in mortality between saline and albumin infusion for critically ill patients.^[24]
Blood transfusion may be considered in the presence of profound anemia or massive hemorrhage.^[21]
Hyperchloremic acidosis may be associated with the use of isotonic saline solution.^[25]

2. Rate of fluid administration (R)

Based on the level of pulmonary capillary wedge pressure or central venous pressure, a volume of 50, 100, or 200 ml of fluid is administered over a 10-minute interval through a peripheral venous catheter.^[21]

Baseline PCWP (mm Hg)	Baseline CVP (cm H₂O)	Rate of fluid administration
≥16	≥14	50 mL over 10 minutes
<16 but ≥12	<14 but ≥8	100 mL over 10 minutes
<12	<8	200 mL over 10 minutes

3. Objective (O)

Fluid administration should be titrated to reach predetermined clinical endpoints such as resolution of tachycardia or oliguria, improved skin perfusion or level of consciousness, normalization of lactate concentrations, and restoration of adequate blood pressure or ventricular filling pressure.^[23]

4. Limits (L)

Fluid administration should be stopped if the safety limits are violated to minimize the risk of developing pulmonary edema.
Inotropes, vasodilators, or mechanical circulatory device may be required if signs of hypoperfusion persist despite optimal fluid loading.
Hemodynamic safety limits based on PCWP (the 7–3 rule) or CVP (the 5–2 rule):^[21]

↑ PCWP (mm Hg)	↑ CVP (cm H₂O)	Action
≥7	≥5	Stop fluid administration
<7 but >3	<5 but >2	Wait and recheck pressure after 10 minutes
≤3	≤2	Continue fluid administration

Pulmonary Congestion

Findings suggestive of cardiogenic pulmonary edema:^[26]

History and clinical manifestations

Cough
Dyspnea
Expectoration of frothy sputum
Orthopnea
Paroxysmal nocturnal dyspnea
Signs and symptoms of heart failure
Signs and symptoms of hypoxemia
Signs and symptoms of myocardial ischemia
Signs and symptoms of valvular dysfunction
Tachypnea

Physical examination

Cool extremities
Heart murmurs
Hepatomegaly
Inspiratory crackles or rhonchi
Jugular venous distention
S3 gallop
Peripheral edema

Laboratory and hemodynamic findings

BNP > 500 pg/mL
PCWP >18 mm Hg

Radiologic findings

Central infiltrates with peripheral sparing
Cephalization of pulmonary vessels
Enlarged cardiac silhouette
Enlargement of peribronchovascular spaces
Increased opacity of acinar areas that coalesce into frank consolidations
Kerley B lines
Peribronchial cuffing
Pleural effusions
Vascular pedicle width >70 mm

Radiologic manifestations of pulmonary congestion reflect the extent of elevation in wedge pressure:^[5]

PCWP (mm Hg)	Phase of Pulmonary Congestion	Findings on Chest Radiograph
18–20	Onset of pulmonary congestion	Redistribution of pulmonary flow to the upper lobes ("cephalization") and Kerley lines
20–25	Moderate congestion	Diminished clarity of the borders of medium-sized pulmonary vessels ("perihilar haze")
25–30	Severe congestion	Radiolucent grapelike clusters surrounded by radiodense fluid ("periacinar rosette")
>30	Onset of pulmonary edema	Coalescence of periacinar rosettes resulting in "Bat's wing" opacities

Furosemide

Dosage and Administration^[12]^[27]

For acute pulmonary edema, the initial dose is 40 mg injected slowly intravenously (over 1 to 2 minutes).
If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes).

Contraindications

Anuria
Hypersensitivity to furosemide

Morphine

Dosage and Administration^[12]^[28]^[29]

Morphine may cause respiratory depression or exacerbate hypotension in volume-depleted patients.
Morphine may be used adjunctively in the treatment of acute pulmonary edema at a dose of 2–4 mg (slow IV injection over 1–5 minutes) every 5–30 minutes as needed.

Contraindications

Hypersensitivity to morphine sulfate is one of the contraindications to its use.
Morphine should not be used in convulsive states, such as those occurring in status epilepticus, tetanus, and strychnine poisoning.
Morphine is also contraindicated in the following conditions: respiratory insufficiency or depression; bronchial asthma; heart failure secondary to chronic lung disease; cardiac arrhythmias; increased intracranial or cerebrospinal pressure; head injuries; brain tumor; acute alcoholism; and delirium tremens.

Afterload Optimization

Nitroglycerin

Dosage and Administration^[12]^[13]^[17]

Suggested Initial Dilution:

Nitroglycerin must be diluted in dextrose (5%) injection or sodium chloride (0.9%) injection prior to its infusion. Transfer 50 mg of nitroglycerin into a 500 mL glass bottle of either dextrose (5%) injection or sodium chloride injection (0.9%). This yields a final concentration of 100 μg/mL. Diluting 5 mg nitroglycerin into 100 mL will yield a final concentration of 50 μg/mL.

Suggested Maintenance Dilution:

Consider the fluid requirements of the patient as well as the expected duration of infusion in selecting the appropriate dilution of Nitroglycerin Injection.
The concentration of nitroglycerin should not exceed 400 μg/mL.

Suggested Regimen:

Severe hypotension and shock may occur with even small doses of nitroglycerin. This drug should therefore be used with caution in patients who may be volume depleted or who, for whatever reason, are already hypotensive. Hypotension induced by nitroglycerin may be accompanied by paradoxical bradycardia and increased angina pectoris.
The initial dosage should be 5 μg/min delivered through an infusion pump. Subsequent titration must be adjusted to the clinical situation, with dose increments becoming more cautious as partial response is seen.
Initial titration should be in 5 μg/min increments, with increases every 3–5 minutes until some response is noted.
If no response is seen at 20 μg/min, increments of 10 and later 20 μg/min can be used.
Once a partial blood pressure response is observed, the dose increase should be reduced and the interval between increases should be lengthened.

Contraindications

Pericardial tamponade
Restrictive cardiomyopathy
Constrictive pericarditis
Hypersensitivity to nitroglycerin

Nitroprusside

Dosage and Administration^[12]^[13]^[18]^[19]

Suggested Dilution:

Depending on the desired concentration, the solution containing 50 mg of nitroprusside must be further diluted in 250–1000 mL of sterile 5% dextrose injection.

Suggested Regimen:

While the average effective rate in adult and pediatric patients is about 3 μg/kg/min, some patients will become dangerously hypotensive at this rate.
Nitroprusside can induce essentially unlimited blood pressure reduction, the blood pressure must be continuously monitored, using either a continually reinflated sphygmomanometer or (preferably) an intra-arterial pressure sensor. Special caution should be used in elderly patients, since they may be more sensitive to the hypotensive effects of the drug.
Infusion of sodium nitroprusside should be started at a very low rate (0.3 μg/kg/min), with upward titration every few minutes until the desired effect is achieved or the maximum recommended infusion rate (10 μg/kg/min) has been reached.

Contraindications

Sodium nitroprusside should not be used for the treatment of acute congestive heart failure associated with reduced peripheral vascular resistance such as high-output heart failure that may be seen in endotoxic sepsis.
Sodium nitroprusside should not be used in the treatment of compensatory hypertension, where the primary hemodynamic lesion is aortic coarctation or arteriovenous shunting.
Sodium nitroprusside should not be used to produce hypotension during surgery in patients with known inadequate cerebral circulation, or in moribund patients coming to emergency surgery.
Patients with congenital (Leber’s) optic atrophy or with toxic amblyopia have unusually high cyanide/thiocyanate ratios. These rare conditions are probably associated with defective or absent rhodanase, and sodium nitroprusside should be avoided in these patients.

Norepinephrine

Dosage and Administration^[12]^[13]^[14]

Suggested Dilution:

Mix 4 mg of norepinephrine in 250 mL of D5W or D5NS. Avoid dilution in normal saline alone.

Suggested Regimen:

Start at a dose of 0.5–1.0 μg/min IV infusion; titrate to maintain SBP at above 90 mm Hg (up to 30–40 μg/min).

Contraindications

Norepinephrine should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed.
Norepinephrine should also not be given to patients with mesenteric or peripheral vascular thrombosis unless it is necessary as a life-saving procedure.

Dopamine

Dosage and Administration^[12]^[13]^[15]

Suggested Dilution: transfer contents of one or more ampuls or vials by aseptic technique to either 250 mL or 500 mL of one of the following sterile intravenous solutions

Sodium Chloride Injection
Dextrose (5%) Injection
Dextrose (5%) and Sodium Chloride (0.9%) Injection
5% Dextrose in 0.45% Sodium Chloride Solution
Dextrose (5%) in Lactated Ringer’s Solution
Sodium Lactate (1/6 Molar) Injection
Lactated Ringer’s Injection

Suggested Regimen:

Begin administration of diluted solution at doses of 2–5 μg/kg/minute in patients who are likely to respond to modest increments of heart force and renal perfusion.
In more seriously ill patients, begin administration of diluted solution at doses of 5 μg/kg/minute and increase gradually, using 5–10 μg/kg/minute increments, up to 20–50 μg/kg/minute as needed.
If doses of 50 μg/kg/minute are required, it is suggested that urine output be checked frequently. Should the urine flow begin to decrease in the absence of hypotension, reduction of dosage should be considered.
Treatment of all patients requires constant evaluation of therapy in terms of the blood volume, augmentation of myocardial contractility, and distribution of peripheral perfusion. Dosage should be adjusted according to the patient’s response, with particular attention to diminution of established urine flow rate, increasing tachycardia or development of new dysrhythmias as indices for decreasing or temporarily suspending the dosage.

Contraindications

Pheochromocytoma
Uncorrected tachyarrhythmias or ventricular fibrillation

Phenylephrine

Dosage and Administration^[30]^[31]

Suggested Dilution:

Add 10 mg of the drug (1 mL of 1 percent solution) to 500 mL of Dextrose Injection or Sodium Chloride Injection (providing a 1:50,000 solution).

Suggested Regimen:

To raise the blood pressure rapidly, start the infusion at about 100 μg to 180 μg per minute (based on 20 drops per mL this would be 100 to 180 drops per minute).
When the blood pressure is stabilized (at a low normal level for the individual), a maintenance rate of 40 μg to 60 μg per minute usually suffices (based on 20 drops per mL this would be 40 to 60 drops per minute).
If a prompt initial pressor response is not obtained, additional increments of phenylephrine (10 mg or more) are added to the infusion bottle. The rate of flow is then adjusted until the desired blood pressure level is obtained.

Contraindications

Severe hypertension
Ventricular tachycardia
Hypersensitivity to phenylephrine

Vasopressin

Dosage and Administration^[30]^[32]

Suggested Regimen:

Adjunctive use of a low dose of vasopressin (0.01–0.04 U/min) to catecholamine may reduce its dosage requirement in patients with refractory shock.

Contraindications

Anaphylaxis or hypersensitivity to the drug or its components

Cardiac Output Optimization

Dobutamine

Dosage and Administration^[12]^[13]^[16]

Suggested Dilution: dobutamine injection must be further diluted in an IV container. Dilute 20 mL of dobutamine in at least 50 mL of diluent and dilute 40 mL of dobutamine in at least 100 mL of diluent. Use one of the following intravenous solutions as a diluent:

Dextrose Injection 5%
Dextrose 5% and Sodium Chloride 0.45% Injection
Dextrose 5% and Sodium Chloride 0.9% Injection
Dextrose Injection 10%, Isolyte® M with 5% Dextrose Injection
Lactated Ringer’s Injection
5% Dextrose in Lactated Ringer’s Injection
Normosol®-M in D5-W
20% Osmitrol® in Water for Injection
Sodium Chloride Injection 0.9%
Sodium Lactate Injection

Suggested Regimen:

The rate of infusion needed to increase cardiac output usually ranged from 2.5–15 mcg/kg/min.
On rare occasions, infusion rates up to 40 mcg/kg/min have been required to obtain the desired effect.

Contraindications

Idiopathic hypertrophic subaortic stenosis
Hypersensitivity to dobutamine

Milrinone

Dosage and Administration^[30]^[33]

Suggested Regimen:

Milrinone should be administered with a loading dose followed by a continuous infusion (maintenance dose).
Loading dose: 50 μg/kg (slowly over 10 minutes)
Maintenance dose: 0.50 μg/kg/min (0.375–0.75 μg/kg/min)

Contraindications

Hypersensitivity to milrinone

Do's

Don'ts

References

↑ ^1.0 ^1.1 ^1.2 Califf, RM.; Bengtson, JR. (1994). "Cardiogenic shock". N Engl J Med. 330 (24): 1724–30. doi:10.1056/NEJM199406163302406. PMID 8190135. Unknown parameter |month= ignored (help)
↑ Robin, E.; Costecalde, M.; Lebuffe, G.; Vallet, B. (2006). "Clinical relevance of data from the pulmonary artery catheter". Crit Care. 10 Suppl 3: S3. doi:10.1186/cc4830. PMID 17164015.
↑ Hollenberg, SM.; Kavinsky, CJ.; Parrillo, JE. (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815. Unknown parameter |month= ignored (help)
↑ ^4.0 ^4.1 Goldberg, RJ.; Gore, JM.; Alpert, JS.; Osganian, V.; de Groot, J.; Bade, J.; Chen, Z.; Frid, D.; Dalen, JE. (1991). "Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988". N Engl J Med. 325 (16): 1117–22. doi:10.1056/NEJM199110173251601. PMID 1891019. Unknown parameter |month= ignored (help)
↑ ^5.0 ^5.1 ^5.2 Forrester, JS.; Diamond, G.; Chatterjee, K.; Swan, HJ. (1976). "Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts)". N Engl J Med. 295 (24): 1356–62. doi:10.1056/NEJM197612092952406. PMID 790191. Unknown parameter |month= ignored (help)
↑ ^6.0 ^6.1 Forrester, JS.; Diamond, G.; Chatterjee, K.; Swan, HJ. (1976). "Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts)". N Engl J Med. 295 (25): 1404–13. doi:10.1056/NEJM197612162952505. PMID 790194. Unknown parameter |month= ignored (help)
↑ ^7.0 ^7.1 Reynolds, HR.; Hochman, JS. (2008). "Cardiogenic shock: current concepts and improving outcomes". Circulation. 117 (5): 686–97. doi:10.1161/CIRCULATIONAHA.106.613596. PMID 18250279. Unknown parameter |month= ignored (help)
↑ Thygesen, K.; Alpert, JS.; Jaffe, AS.; Simoons, ML.; Chaitman, BR.; White, HD.; Thygesen, K.; Alpert, JS.; White, HD. (2012). "Third universal definition of myocardial infarction". J Am Coll Cardiol. 60 (16): 1581–98. doi:10.1016/j.jacc.2012.08.001. PMID 22958960. Unknown parameter |month= ignored (help)
↑ Braunwald, E.; Antman, EM.; Beasley, JW.; Califf, RM.; Cheitlin, MD.; Hochman, JS.; Jones, RH.; Kereiakes, D.; Kupersmith, J. (2000). "ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)". J Am Coll Cardiol. 36 (3): 970–1062. PMID 10987629. Unknown parameter |month= ignored (help)
↑ Anderson, JL.; Adams, CD.; Antman, EM.; Bridges, CR.; Califf, RM.; Casey, DE.; Chavey, WE.; Fesmire, FM.; Hochman, JS. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888. Unknown parameter |month= ignored (help)
↑ Gibbons, RJ.; Abrams, J.; Chatterjee, K.; Daley, J.; Deedwania, PC.; Douglas, JS.; Ferguson, TB.; Fihn, SD.; Fraker, TD. (2003). "ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina)". Circulation. 107 (1): 149–58. PMID 12515758. Unknown parameter |month= ignored (help)
↑ ^12.00 ^12.01 ^12.02 ^12.03 ^12.04 ^12.05 ^12.06 ^12.07 ^12.08 ^12.09 ^12.10 ^12.11 Handbook of Emergency Cardiovascular Care for Healthcare Providers. ISBN 1616690003.
↑ ^13.0 ^13.1 ^13.2 ^13.3 ^13.4 ^13.5 ^13.6 ^13.7 ^13.8 ^13.9 "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation". Circulation. 102 (8 Suppl): I172–203. 2000. PMID 10966673. Unknown parameter |month= ignored (help)
↑ ^14.0 ^14.1 "NOREPINEPHRINE BITARTRATE INJECTION".
↑ ^15.0 ^15.1 "DOPAMINE HCL INJECTION, SOLUTION [AMERICAN REGENT, INC.]".
↑ ^16.0 ^16.1 "DOBUTAMINE (DOBUTAMINE HYDROCHLORIDE) INJECTION, SOLUTION [HOSPIRA, INC.]".
↑ ^17.0 ^17.1 "NITROGLYCERIN INJECTION, SOLUTION [AMERICAN REGENT, INC.]".
↑ ^18.0 ^18.1 "NITROPRESS (SODIUM NITROPRUSSIDE) INJECTION, SOLUTION, CONCENTRATE [HOSPIRA, INC.]".
↑ ^19.0 ^19.1 Chatterjee, K.; Parmley, WW.; Ganz, W.; Forrester, J.; Walinsky, P.; Crexells, C.; Swan, HJ. (1973). "Hemodynamic and metabolic responses to vasodilator therapy in acute myocardial infarction". Circulation. 48 (6): 1183–93. PMID 4762476. Unknown parameter |month= ignored (help)
↑ Crexells, C.; Chatterjee, K.; Forrester, JS.; Dikshit, K.; Swan, HJ. (1973). "Optimal level of filling pressure in the left side of the heart in acute myocardial infarction". N Engl J Med. 289 (24): 1263–6. doi:10.1056/NEJM197312132892401. PMID 4749545. Unknown parameter |month= ignored (help)
↑ ^21.0 ^21.1 ^21.2 ^21.3 Weil, MH.; Henning, RJ. "New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture". Anesth Analg. 58 (2): 124–32. PMID 571235.
↑ Vincent, JL. (2011). "Let's give some fluid and see what happens versus the mini-fluid challenge". Anesthesiology. 115 (3): 455–6. doi:10.1097/ALN.0b013e318229a521. PMID 21792055. Unknown parameter |month= ignored (help)
↑ ^23.0 ^23.1 Vincent, JL.; Weil, MH. (2006). "Fluid challenge revisited". Crit Care Med. 34 (5): 1333–7. doi:10.1097/01.CCM.0000214677.76535.A5. PMID 16557164. Unknown parameter |month= ignored (help)
↑ Finfer, S.; Bellomo, R.; Boyce, N.; French, J.; Myburgh, J.; Norton, R. (2004). "A comparison of albumin and saline for fluid resuscitation in the intensive care unit". N Engl J Med. 350 (22): 2247–56. doi:10.1056/NEJMoa040232. PMID 15163774. Unknown parameter |month= ignored (help)
↑ Scheingraber, S.; Rehm, M.; Sehmisch, C.; Finsterer, U. (1999). "Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery". Anesthesiology. 90 (5): 1265–70. PMID 10319771. Unknown parameter |month= ignored (help)
↑ Ware, LB.; Matthay, MA. (2005). "Clinical practice. Acute pulmonary edema". N Engl J Med. 353 (26): 2788–96. doi:10.1056/NEJMcp052699. PMID 16382065. Unknown parameter |month= ignored (help)
↑ "FUROSEMIDE INJECTION [AMERICAN REGENT, INC.]".
↑ "MORPHINE SULFATE INJECTION, SOLUTION, CONCENTRATE".
↑ O'Connor, RE.; Brady, W.; Brooks, SC.; Diercks, D.; Egan, J.; Ghaemmaghami, C.; Menon, V.; O'Neil, BJ.; Travers, AH. (2010). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S787–817. doi:10.1161/CIRCULATIONAHA.110.971028. PMID 20956226. Unknown parameter |month= ignored (help)
↑ ^30.0 ^30.1 ^30.2 Hollenberg, SM. (2011). "Vasoactive drugs in circulatory shock". Am J Respir Crit Care Med. 183 (7): 847–55. doi:10.1164/rccm.201006-0972CI. PMID 21097695. Unknown parameter |month= ignored (help)
↑ "PHENYLEPHRINE HYDROCHLORIDE INJECTION [BAXTER HEALTHCARE CORPORATION]".
↑ "PITRESSIN (VASOPRESSIN) INJECTION [JHP PHARMACEUTICALS LLC]".
↑ "MILRINONE LACTATE (MILRINONE LACTATE) INJECTION, SOLUTION [BAXTER HEALTHCARE CORPORATION]".

[Califf-1994-1] 1.0 ^1.1 ^1.2 Califf, RM.; Bengtson, JR. (1994). "Cardiogenic shock". N Engl J Med. 330 (24): 1724–30. doi:10.1056/NEJM199406163302406. PMID 8190135. Unknown parameter |month= ignored (help)

[Robin-2006-2] Robin, E.; Costecalde, M.; Lebuffe, G.; Vallet, B. (2006). "Clinical relevance of data from the pulmonary artery catheter". Crit Care. 10 Suppl 3: S3. doi:10.1186/cc4830. PMID 17164015.

[Hollenberg-1999-3] Hollenberg, SM.; Kavinsky, CJ.; Parrillo, JE. (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815. Unknown parameter |month= ignored (help)

[Goldberg-1991-4] 4.0 ^4.1 Goldberg, RJ.; Gore, JM.; Alpert, JS.; Osganian, V.; de Groot, J.; Bade, J.; Chen, Z.; Frid, D.; Dalen, JE. (1991). "Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988". N Engl J Med. 325 (16): 1117–22. doi:10.1056/NEJM199110173251601. PMID 1891019. Unknown parameter |month= ignored (help)

[Forrester-1976-5] 5.0 ^5.1 ^5.2 Forrester, JS.; Diamond, G.; Chatterjee, K.; Swan, HJ. (1976). "Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts)". N Engl J Med. 295 (24): 1356–62. doi:10.1056/NEJM197612092952406. PMID 790191. Unknown parameter |month= ignored (help)

[Forrester-1976-2-6] 6.0 ^6.1 Forrester, JS.; Diamond, G.; Chatterjee, K.; Swan, HJ. (1976). "Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts)". N Engl J Med. 295 (25): 1404–13. doi:10.1056/NEJM197612162952505. PMID 790194. Unknown parameter |month= ignored (help)

[Reynolds-2008-7] 7.0 ^7.1 Reynolds, HR.; Hochman, JS. (2008). "Cardiogenic shock: current concepts and improving outcomes". Circulation. 117 (5): 686–97. doi:10.1161/CIRCULATIONAHA.106.613596. PMID 18250279. Unknown parameter |month= ignored (help)

[Thygesen-2012-8] Thygesen, K.; Alpert, JS.; Jaffe, AS.; Simoons, ML.; Chaitman, BR.; White, HD.; Thygesen, K.; Alpert, JS.; White, HD. (2012). "Third universal definition of myocardial infarction". J Am Coll Cardiol. 60 (16): 1581–98. doi:10.1016/j.jacc.2012.08.001. PMID 22958960. Unknown parameter |month= ignored (help)

[Braunwald-2000-9] Braunwald, E.; Antman, EM.; Beasley, JW.; Califf, RM.; Cheitlin, MD.; Hochman, JS.; Jones, RH.; Kereiakes, D.; Kupersmith, J. (2000). "ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)". J Am Coll Cardiol. 36 (3): 970–1062. PMID 10987629. Unknown parameter |month= ignored (help)

[Anderson-2011-10] Anderson, JL.; Adams, CD.; Antman, EM.; Bridges, CR.; Califf, RM.; Casey, DE.; Chavey, WE.; Fesmire, FM.; Hochman, JS. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888. Unknown parameter |month= ignored (help)

[Gibbons-2003-11] Gibbons, RJ.; Abrams, J.; Chatterjee, K.; Daley, J.; Deedwania, PC.; Douglas, JS.; Ferguson, TB.; Fihn, SD.; Fraker, TD. (2003). "ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina)". Circulation. 107 (1): 149–58. PMID 12515758. Unknown parameter |month= ignored (help)

[isbn1616690003-12] 12.00 ^12.01 ^12.02 ^12.03 ^12.04 ^12.05 ^12.06 ^12.07 ^12.08 ^12.09 ^12.10 ^12.11 Handbook of Emergency Cardiovascular Care for Healthcare Providers. ISBN 1616690003.

[-2000-13] 13.0 ^13.1 ^13.2 ^13.3 ^13.4 ^13.5 ^13.6 ^13.7 ^13.8 ^13.9 "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation". Circulation. 102 (8 Suppl): I172–203. 2000. PMID 10966673. Unknown parameter |month= ignored (help)

[NOREPINEPHRINE_BITARTRATE_INJECTION-14] 14.0 ^14.1 "NOREPINEPHRINE BITARTRATE INJECTION".

[DOPAMINE_HCL_injection,_solution-15] 15.0 ^15.1 "DOPAMINE HCL INJECTION, SOLUTION [AMERICAN REGENT, INC.]".

[DOBUTAMINE_(DOBUTAMINE_HYDROCHLORIDE)_INJECTION,_SOLUTION-16] 16.0 ^16.1 "DOBUTAMINE (DOBUTAMINE HYDROCHLORIDE) INJECTION, SOLUTION [HOSPIRA, INC.]".

[NITROGLYCERIN_INJECTION,_SOLUTION-17] 17.0 ^17.1 "NITROGLYCERIN INJECTION, SOLUTION [AMERICAN REGENT, INC.]".

[NITROPRESS_(SODIUM_NITROPRUSSIDE)_INJECTION-18] 18.0 ^18.1 "NITROPRESS (SODIUM NITROPRUSSIDE) INJECTION, SOLUTION, CONCENTRATE [HOSPIRA, INC.]".

[Chatterjee-1973-19] 19.0 ^19.1 Chatterjee, K.; Parmley, WW.; Ganz, W.; Forrester, J.; Walinsky, P.; Crexells, C.; Swan, HJ. (1973). "Hemodynamic and metabolic responses to vasodilator therapy in acute myocardial infarction". Circulation. 48 (6): 1183–93. PMID 4762476. Unknown parameter |month= ignored (help)

[Crexells-1973-20] Crexells, C.; Chatterjee, K.; Forrester, JS.; Dikshit, K.; Swan, HJ. (1973). "Optimal level of filling pressure in the left side of the heart in acute myocardial infarction". N Engl J Med. 289 (24): 1263–6. doi:10.1056/NEJM197312132892401. PMID 4749545. Unknown parameter |month= ignored (help)

[Weil-fluid1-21] 21.0 ^21.1 ^21.2 ^21.3 Weil, MH.; Henning, RJ. "New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture". Anesth Analg. 58 (2): 124–32. PMID 571235.

[Vincent-2011-22] Vincent, JL. (2011). "Let's give some fluid and see what happens versus the mini-fluid challenge". Anesthesiology. 115 (3): 455–6. doi:10.1097/ALN.0b013e318229a521. PMID 21792055. Unknown parameter |month= ignored (help)

[Weil-fluid2-23] 23.0 ^23.1 Vincent, JL.; Weil, MH. (2006). "Fluid challenge revisited". Crit Care Med. 34 (5): 1333–7. doi:10.1097/01.CCM.0000214677.76535.A5. PMID 16557164. Unknown parameter |month= ignored (help)

[Finfer-2004-24] Finfer, S.; Bellomo, R.; Boyce, N.; French, J.; Myburgh, J.; Norton, R. (2004). "A comparison of albumin and saline for fluid resuscitation in the intensive care unit". N Engl J Med. 350 (22): 2247–56. doi:10.1056/NEJMoa040232. PMID 15163774. Unknown parameter |month= ignored (help)

[Scheingraber-1999-25] Scheingraber, S.; Rehm, M.; Sehmisch, C.; Finsterer, U. (1999). "Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery". Anesthesiology. 90 (5): 1265–70. PMID 10319771. Unknown parameter |month= ignored (help)

[Ware-2005-26] Ware, LB.; Matthay, MA. (2005). "Clinical practice. Acute pulmonary edema". N Engl J Med. 353 (26): 2788–96. doi:10.1056/NEJMcp052699. PMID 16382065. Unknown parameter |month= ignored (help)

[FUROSEMIDE_injection-27] "FUROSEMIDE INJECTION [AMERICAN REGENT, INC.]".

[MORPHINE_SULFATE_INJECTION-28] "MORPHINE SULFATE INJECTION, SOLUTION, CONCENTRATE".

[O'Connor-2010-29] O'Connor, RE.; Brady, W.; Brooks, SC.; Diercks, D.; Egan, J.; Ghaemmaghami, C.; Menon, V.; O'Neil, BJ.; Travers, AH. (2010). "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S787–817. doi:10.1161/CIRCULATIONAHA.110.971028. PMID 20956226. Unknown parameter |month= ignored (help)

[Hollenberg-2011-30] 30.0 ^30.1 ^30.2 Hollenberg, SM. (2011). "Vasoactive drugs in circulatory shock". Am J Respir Crit Care Med. 183 (7): 847–55. doi:10.1164/rccm.201006-0972CI. PMID 21097695. Unknown parameter |month= ignored (help)

[PHENYLEPHRINE_HYDROCHLORIDE_INJECTION-31] "PHENYLEPHRINE HYDROCHLORIDE INJECTION [BAXTER HEALTHCARE CORPORATION]".

[VASOPRESSIN_INJECTION-32] "PITRESSIN (VASOPRESSIN) INJECTION [JHP PHARMACEUTICALS LLC]".

[MILRINONE_LACTATE_INJECTION-33] "MILRINONE LACTATE (MILRINONE LACTATE) INJECTION, SOLUTION [BAXTER HEALTHCARE CORPORATION]".

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

[23]

[24]

[25]

[26]

[27]

[28]

[29]

[30]

[31]

[32]

[33]

@@ Line 1: / Line 1: @@
 <div style="width: 1px; height: 1px; background-color: #999999; position: fixed; top: 10px; left: 10px"></div>
-<div style="width: 90%; -webkit-user-select: none;">
+<div style="width: 87%; -webkit-user-select: none;">
-{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 5%; background: #A8A8A8; position: fixed; top: 250px; right: 20px; border-radius: 10px 10px 10px 10px;" cellpadding="0" cellspacing="0";
+{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 12.5%; background: #A8A8A8; position: fixed; top: 250px; right: 20px; border-radius: 10px 10px 10px 10px;" cellpadding="0" cellspacing="0";
 |-
 ! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align=center| {{fontcolor|#2B3B44|Cardiogenic Shock<BR>Resident Survival Guide}}
@@ Line 11: / Line 11: @@
 ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|FIRE]]
 |-
-! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
+! style="font-size: 60%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Emergency Revascularization &#91;Return to FIRE&#93;|Emergency Revascularization]]
 |-
-! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
+! style="font-size: 50%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Complete Diagnostic Approach &#91;Return to FIRE&#93;|Complete Diagnostic Approach]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Diagnostic Criteria &#91;Return to FIRE&#93;|Diagnostic Criteria]]
+: <div style="font-size: 80%;">[[{{PAGENAME}}#Criteria for Cardiogenic Shock|Cardiogenic Shock]]</div>
+: <div style="font-size: 80%;">[[{{PAGENAME}}#Criteria for Acute Myocardial Infarction|Acute Myocardial Infarction]]</div>
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Maintenance of Blood Pressure &#91;Return to FIRE&#93;|Blood Pressure Maintenance]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Optimization of Hemodynamic Status &#91;Return to FIRE&#93;|Hemodynamic Optimization]]
 |-
 ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Do's|Do's]]
@@ Line 19: / Line 27: @@
 ! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
 |}
-__NOTOC__
+__NOEDITSECTION____NOTOC__
-{{CMG}}; {{AE}} [[User:Ahmed Zaghw|Ahmed Zaghw, MBChB.]] [mailto:ahmedzaghw@wikidoc.org]
+==Overview==
+The clinical definition of [[cardiogenic shock]] includes decreased [[cardiac output]] with evidence of tissue [[hypoxia]] in the presence of adequate intravascular volume.<ref name="Califf-1994">{{Cite journal  | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref>
+==Causes==
+===Life Threatening Causes===
+Cardiogenic shock is a life-threatening condition and must be treated as such irrespective of the underlying cause.
+===Common Causes===
+:* ''Arrhythmic''
+::* [[Atrioventricular block]]
+::* [[Sinoatrial block]]
+::* [[Supraventricular tachycardia]]
+::* [[Ventricular tachycardia]]
+:* ''Mechanical''
+::* [[Mitral regurgitation|Acute mitral regurgitation]] ([[papillary muscle rupture]], [[chordae tendinae]] [[rupture]])
+::* [[Myocardial rupture|Free wall rupture]]
+::* [[Hypertrophic cardiomyopathy]]
+::* [[Left ventricle|Obstruction to left ventricular filling]] ([[mitral stenosis]], [[left atrial myxoma]])
+::* [[Left ventricular outflow tract obstruction|Obstruction to left ventricular outflow tract]] ([[aortic stenosis]], [[hypertrophic obstructive cardiomyopathy]])
+::* [[Ventricular septal defect]]
+:* ''Myopathic''
+::* [[Cardiomyopathy]]
+::* [[Myocardial contusion]]
+::* [[Myocardial infarction]]
+::* [[Myocarditis]]
+::* [[Myxedema coma]]
+::* [[ischemia|Postischemic]] [[myocardial stunning]]
+::* [[Sepsis|Septic myocardial depression]]
+:* ''Pharmacologic''
+::* [[Anthracycline]]s
+::* [[Calcium channel blockers]]
+''Click '''[[Cardiogenic shock causes|here]]''' for the complete list of causes.''
 ==FIRE: Focused Initial Rapid Evaluation==
@@ Line 29: / Line 72: @@
 A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="Robin-2006">{{Cite journal  | last1 = Robin | first1 = E. | last2 = Costecalde | first2 = M. | last3 = Lebuffe | first3 = G. | last4 = Vallet | first4 = B. | title = Clinical relevance of data from the pulmonary artery catheter. | journal = Crit Care | volume = 10 Suppl 3 | issue =  | pages = S3 | month =  | year = 2006 | doi = 10.1186/cc4830 | PMID = 17164015 }}</ref>
-<span style="font-size:85%">Boxes in the red signify that an urgent management is needed.</span>
+<span style="font-size:85%">Boxes in <span style="background: #FEDAEC;">red</span> signify that an urgent management is needed.</span>
 <span style="font-size: 85%;">
@@ Line 42: / Line 85: @@
 LFT, liver function test;
 MAP, mean arterial pressure;
-MVO2, mixed venous oxygen saturation;
 PCWP, pulmonary capillary wedge pressure;
 PT, prothrombin time;
@@ Line 49: / Line 91: @@
 SBP, systolic blood pressure;
 ScvO2, central venous oxygen saturation;
+SvO2, mixed venous oxygen saturation;
 SMA-7, sequential multiple analysis-7.
 </span>
+<div style="font-size: 80%;">
 {{Family tree/start}}
-{{Family tree|boxstyle=width: 400px; text-align: left; font-size: 90%; padding: 0px;| | | | | A01 | | | |A01=<div style="padding: 15px;"><BIG>'''Does the patient have cardinal findings that increase the pretest probability of [[cardiogenic shock|<span style="color: #000000;">cardiogenic shock</span>]]?'''</BIG>
+{{Family tree|boxstyle=width: 400px; text-align: left; font-size: 90%; padding: 0px;| | | | | | | | A01 | | | |A01=<div style="padding: 15px;"><BIG>'''Does the patient have cardinal findings that increase the pretest probability of [[cardiogenic shock|<span style="color: #000000;">cardiogenic shock</span>]]?'''</BIG>
 ❑&nbsp;&nbsp;Evidence of end-organ [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]
@@ Line 60: / Line 104: @@
 : ❑&nbsp;&nbsp;[[Cyanosis|<span style="color: #000000;">Cyanosis</span>]]
 : ❑&nbsp;&nbsp;[[Oliguria|<span style="color: #000000;">Oliguria</span>]] ([[urine output|<span style="color: #000000;">urine output</span>]] &lt;0.5 mL/kg/h)
-: ❑&nbsp;&nbsp;Sustained [[hypotension|<span style="color: #000000;">hypotension</span>]]
+: ❑&nbsp;&nbsp;Sustained [[hypotension|<span style="color: #000000;">hypotension</span>]] (≥30 min)
-:: ❑&nbsp;&nbsp;[[SBP|<span style="color: #000000;">SBP</span>]] &lt;90 mm Hg for ≥30 min ''or''
+:: ❑&nbsp;&nbsp;[[SBP|<span style="color: #000000;">SBP</span>]] &lt;90 mm Hg ''or''
-:: ❑&nbsp;&nbsp;[[MAP|<span style="color: #000000;">MAP</span>]] ↓ &gt;30 mm Hg below baseline for ≥30 min
+:: ❑&nbsp;&nbsp;[[MAP|<span style="color: #000000;">MAP</span>]] ↓ &gt;30 mm Hg below baseline
 ❑&nbsp;&nbsp;Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue [[hypoperfusion|<span style="color: #000000;">hypoperfusion</span>]]</div>}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%;| |,|-|-|-|^|-|-|-|.| |}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%;| | | | |,|-|-|-|^|-|-|-|.| |}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A02 | | | | | | A03 |A02=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>YES</BIG></div>|A03=<div style="text-align: center; background: #FA8072; color: #F8F8FF; font-weight: bold; padding: 15px;"><BIG>NO</BIG></div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | A02 | | | | | | A03 |A02=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 5px; font-weight: bold;"><BIG>YES</BIG></div>|A03=<div style="text-align: center; background: #FEDAEC; color: #000000; font-weight: bold; padding: 5px;"><BIG>NO</BIG></div>}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | |!| |}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FEDAEC; border-top: 0px;| | | | A04 | | | | | | A05 |A04=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 5px; font-weight: bold;"><BIG>Cardiogenic shock suspected</BIG><BR>''[[{{PAGENAME}}#Criteria for Cardiogenic Shock|<span style="color: #000000;">(click for details on criteria)</span>]]''</div>
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FA8072| A04 | | | | | | A05 |A04=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>Cardiogenic shock suspected</BIG></div>
+|A05=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 5px; font-weight: bold;"><BIG>Proceed to</BIG><br>[[shock resident survival guide|<span style="color: #000000;">shock resident survival guide</span>]]</div>}}
-|A05=<div style="text-align: center; background: #FA8072; color: #FFFFFF; padding: 15px; font-weight: bold;"><BIG>'''Proceed to <br> [[shock resident survival guide|<span style="color: #FFFFFF;">shock resident survival guide</span>]]'''</BIG></div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | |!| | | | | | | | | |}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | A06 | | | | | | | | |A06=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 5px;"><BIG>'''Immediate steps'''</BIG></div>}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A06 | | | | | | | | |A06=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate management'''</BIG>
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | A07 | | | | | | | | |A07=<div style="background: #FEDAEC; color: #000000; padding: 15px;"><BIG>'''''Initial management'''''</BIG>
+❑&nbsp;&nbsp;Oxygen ± [[mechanical ventilation|<span style="color: #000000;">ventilatory support</span>]]
+❑&nbsp;&nbsp;[[ECG|<span style="color: #000000;">ECG monitor</span>]]
+❑&nbsp;&nbsp;[[Pulse oximeter|<span style="color: #000000;">Pulse oximeter</span>]]
+❑&nbsp;&nbsp;[[Sphygmomanometer|<span style="color: #000000;">Sphygmomanometer</span>]] or [[Arterial line|<span style="color: #000000;">arterial line</span>]]
+❑&nbsp;&nbsp;[[Intravenous therapy#Peripheral IV lines|<span style="color: #000000;">Large-bore peripheral venous lines</span>]]
+❑&nbsp;&nbsp;[[Central venous catheter|<span style="color: #000000;">Central venous catheter</span>]]
+❑&nbsp;&nbsp;[[Foley catheter|<span style="color: #000000;">Bladder catheterization</span>]]
+❑&nbsp;&nbsp;Hold [[antihypertensive|<span style="color: #000000;">antihypertensive medications</span>]]
+❑&nbsp;&nbsp;± Correct [[tachyarrhythmia|<span style="color: #000000;">tachy-</span>]] or [[bradyarrhythmia|<span style="color: #000000;">bradyarrhythmia</span>]]</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | A08 | | | | | | | | |A08=<div style="background: #FEDAEC; color: #000000; padding: 15px;"><BIG>'''''Initial workup'''''</BIG>
+❑&nbsp;&nbsp;[[Arterial blood gas|<span style="color: #000000;">Arterial blood gas</span>]]
+❑&nbsp;&nbsp;[[CBC|<span style="color: #000000;">CBC</span>]]/[[Differential blood count (patient information)|<span style="color: #000000;">DC</span>]]/[[Basic metabolic panel|<span style="color: #000000;">SMA-7</span>]]/[[LFT|<span style="color: #000000;">LFT</span>]]/[[PT|<span style="color: #000000;">PT</span>]]/[[PTT|<span style="color: #000000;">PTT</span>]]/[[INR|<span style="color: #000000;">INR</span>]]
+❑&nbsp;&nbsp;[[Troponin|<span style="color: #000000;">Cardiac troponins</span>]], [[CK-MB|<span style="color: #000000;">CK-MB</span>]]
+❑&nbsp;&nbsp;[[Brain natriuretic peptide|<span style="color: #000000;">BNP</span>]], [[Brain natriuretic peptide|<span style="color: #000000;">NT-proBNP</span>]]
+❑&nbsp;&nbsp;[[Lactate|<span style="color: #000000;">Lactate</span>]]
+❑&nbsp;&nbsp;[[ECG|<span style="color: #000000;">12-Lead ECG</span>]]
+❑&nbsp;&nbsp;[[CXR|<span style="color: #000000;">Chest radiograph</span>]]
+❑&nbsp;&nbsp;[[Echocardiography|<span style="color: #000000;">Echocardiography</span>]]</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | |!| | | | | | | | | |}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | A09 | | | | | | | | |A09=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 5px; font-weight: bold;"><BIG>Maintain adequate blood pressure</BIG><BR>''[[{{PAGENAME}}#Maintenance of Blood Pressure &#91;Return to FIRE&#93;|<span style="color: #000000;">(click for details)</span>]]''</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | A10 | | | | | | | | |A10=<div style="background: #FEDAEC; color: #000000; padding: 15px;">
+'''''SBP <70 mm Hg:'''''
+❑&nbsp;&nbsp;[[Norepinephrine|<span style="color: #000000;">Norepinephrine</span>]]
+: ❑&nbsp;&nbsp;Initial dose: 0.5–1.0 μg/min
+: ❑&nbsp;&nbsp;Maximum dose: 30–40 μg/min
+: ❑&nbsp;&nbsp;Titrate to [[SBP|<span style="color: #000000;">SBP</span>]] &gt;90 mm Hg
+'''''SBP 70–100 mm Hg with symptoms:'''''
+❑&nbsp;&nbsp;[[Dopamine|<span style="color: #000000;">Dopamine</span>]]
+: ❑&nbsp;&nbsp;Cardiac dose: 5.0–10 μg/kg/min
+: ❑&nbsp;&nbsp;Pressor dose: 10–20 μg/kg/min
+: ❑&nbsp;&nbsp;Maximum dose: 20–50 μg/kg/min
+'''''SBP 70–100 mm Hg w/o symptoms:'''''
+❑&nbsp;&nbsp;[[Dobutamine|<span style="color: #000000;">Dobutamine</span>]]
+: ❑&nbsp;&nbsp;Usual dose: 2.0–20 μg/kg/min
+: ❑&nbsp;&nbsp;Maximum dose: 40 μg/kg/min
+: ❑&nbsp;&nbsp;Avoid ↑ HR by >10% of baseline
+'''''SBP >100 mm Hg:'''''
+❑&nbsp;&nbsp;[[Nitroglycerin|<span style="color: #000000;">Nitroglycerin</span>]]
+: ❑&nbsp;&nbsp;Initial dose: 5.0 μg/min
+: ❑&nbsp;&nbsp;Titrate by 10–20 μg/min q 3–5 min
+❑&nbsp;&nbsp;[[Nitroprusside|<span style="color: #000000;">Nitroprusside</span>]]
+: ❑&nbsp;&nbsp;Initial dose: 0.3 μg/kg/min
+: ❑&nbsp;&nbsp;Usual dose: 3.0–5.0 μg/kg/min
+: ❑&nbsp;&nbsp;Maximum dose: 10 μg/kg/min</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | |!| | | | | | | | | |}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | A09 | | | | | | | | |A09=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 5px; font-weight: bold;"><BIG>'''Acute coronary syndrome likely?'''</BIG><BR>''[[{{PAGENAME}}#Criteria for Acute Myocardial Infarction|<span style="color: #000000;">(click for details on criteria)</span>]]''</div>}}
+{{Family tree|boxstyle=text-align: left; background: #FEDAEC; font-size: 90%; padding: 15px; border-top: 0px;| | | | A20 | | | | | | | | |A20=<div style="color: #000000">❑&nbsp;&nbsp;'''New ischemic ECG changes'''
+❑&nbsp;&nbsp;'''Positive [[cardiac biomarkers|<span style="color: #000000;">cTnT, cTnI, or CK-MB</span>]]'''
+❑&nbsp;&nbsp;'''Anginal pain'''</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |,|-|-|^|-|-|-|.| | | | | | |}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A09 | | | | | A10 | | | | | | | |A09=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 5px; font-weight: bold;"><BIG>YES</BIG></div>|A10=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 5px; font-weight: bold;"><BIG>NO</BIG></div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; background: #FEDAEC; padding: 0px; border-top: 0px;| A09 | | | | | A10 | | | | | | | |A09=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 15px; font-weight: bold;"><BIG>Proceed to<BR>[[{{PAGENAME}}#Emergency Revascularization &#91;Return to FIRE&#93;|<span style="color: #000000;">Emergency Revascularization</span>]]</BIG></div>|A10=<div style="background: #FEDAEC; color: #000000; padding: 15px; font-weight: bold;">❑&nbsp;&nbsp;[[ICU|<span style="color: #000000;">ICU admission</span>]]
+❑&nbsp;&nbsp;[[Pulmonary artery catheter|<span style="color: #000000;">Swan-Ganz catheter</span>]]
+❑&nbsp;&nbsp;[[Cardiology|<span style="color: #000000;">Cardiology consultation</span>]]</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | | | | | |!| | | | | | |}}
+{{Family tree|boxstyle=text-align: center; font-size: 90%; padding: 0px;| | | | | | | | A09 | | | | | | | | |A09=<div style="background: #FEDAEC; color: #000000; padding: 5px; font-weight: bold;"><BIG>Optimize hemodynamic status</BIG><BR>''[[{{PAGENAME}}#Optimization of Hemodynamic Status &#91;Return to FIRE&#93;|<span style="color: #000000;">(click for details)</span>]]''</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | | | | | A10 | | | | | | | | |A10=<div style="background: #FEDAEC; color: #000000; padding: 15px;"><BIG>'''''[[{{PAGENAME}}#Preload Optimization|<span style="color: #000000;">Preload</span>]]'''''</BIG>
+'''Goal: [[PCWP|<span style="color: #000000;">PCWP</span>]] 15–18 mm Hg, [[Central venous pressure|<span style="color: #000000;">CVP</span>]] 8–12 cm H<sub>2</sub>O'''
+❑&nbsp;&nbsp;[[{{PAGENAME}}#Fluid Challenge Protocol|<span style="color: #000000;">Fluid challenge protocol ''("TROL")''</span>]]
+❑&nbsp;&nbsp;± Correct [[pulmonary congestion|<span style="color: #000000;">pulmonary congestion</span>]]
+: ❑&nbsp;&nbsp;[[Furosemide|<span style="color: #000000;">Furosemide</span>]]
+:: ❑&nbsp;&nbsp;Usual dose: 40 mg slow IV injection
+:: ❑&nbsp;&nbsp;May increase dose to 80 mg after 1 hour as needed
+: ❑&nbsp;&nbsp;[[Morphine|<span style="color: #000000;">Morphine</span>]]
+:: ❑&nbsp;&nbsp;Usual dose: 2–4 mg slow IV injection
+:: ❑&nbsp;&nbsp;May repeat dose every 5–30 minutes as needed</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | | | | | A11 | | | | | | | | |A11=<div style="background: #FEDAEC; color: #000000; padding: 15px;"><BIG>'''''[[{{PAGENAME}}#Afterload Optimization|<span style="color: #000000;">Afterload</span>]]'''''</BIG>
+'''Goal: [[MAP|<span style="color: #000000;">MAP</span>]] &gt;65 mm Hg, [[SVR|<span style="color: #000000;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>'''
+❑&nbsp;&nbsp;'''If ↑ MAP & ↑ SVR:'''
-❑&nbsp;&nbsp;[[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
+: ❑&nbsp;&nbsp;Taper [[vasopressor|<span style="color: #000000;">vasopressor</span>]]
-❑&nbsp;&nbsp;[[Pulse oximeter|<span style="color: #FFFFFF;">Pulse oximeter</span>]]
+: ❑&nbsp;&nbsp;± [[Vasodilator|<span style="color: #000000;">Vasodilator</span>]]
-❑&nbsp;&nbsp;[[Arterial blood gas|<span style="color: #FFFFFF;">Arterial blood gas</span>]]
+:: ❑&nbsp;&nbsp;[[Nitroglycerin|<span style="color: #000000;">Nitroglycerin</span>]]
-❑&nbsp;&nbsp;[[Intubation|<span style="color: #FFFFFF;">Intubation</span>]] with [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]]
+::: ❑&nbsp;&nbsp;Initial dose: 5.0 μg/min
-❑&nbsp;&nbsp;[[Intravenous therapy#Peripheral IV lines|<span style="color: #FFFFFF;">Large-bore peripheral venous lines</span>]]
+::: ❑&nbsp;&nbsp;Titrate by 10–20 μg/min q 3–5 min
-❑&nbsp;&nbsp;[[Arterial line|<span style="color: #FFFFFF;">Arterial line</span>]]
+:: ❑&nbsp;&nbsp;[[Nitroprusside|<span style="color: #000000;">Nitroprusside</span>]]
-❑&nbsp;&nbsp;[[Central venous catheter|<span style="color: #FFFFFF;">Central venous catheter</span>]]
+::: ❑&nbsp;&nbsp;Initial dose: 0.3 μg/kg/min
-❑&nbsp;&nbsp;[[Pulmonary artery catheter|<span style="color: #FFFFFF;">Pulmonary artery catheter</span>]]
+::: ❑&nbsp;&nbsp;Usual dose: 3.0–5.0 μg/kg/min
-❑&nbsp;&nbsp;[[Foley catheter|<span style="color: #FFFFFF;">Foley catheter</span>]]
+::: ❑&nbsp;&nbsp;Maximum dose: 10 μg/kg/min
-❑&nbsp;&nbsp;[[ICU|<span style="color: #FFFFFF;">ICU admission</span>]]
+❑&nbsp;&nbsp;'''If ↓ MAP & ↓ SVR:'''
-❑&nbsp;&nbsp;[[Cardiology|<span style="color: #FFFFFF;">Cardiology consultation</span>]]
+: ❑&nbsp;&nbsp;[[vasopressor|<span style="color: #000000;">Vasopressor</span>]]
-❑&nbsp;&nbsp;Hold [[antihypertensive|<span style="color: #FFFFFF;">antihypertensive medications</span>]]</div>}}
+:: ❑&nbsp;&nbsp;[[Norepinephrine|<span style="color: #000000;">Norepinephrine</span>]]
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A07 | | | | | | | | |A07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate workup'''</BIG>
-❑&nbsp;&nbsp;[[CBC|<span style="color: #FFFFFF;">CBC</span>]]/[[Differential blood count (patient information)|<span style="color: #FFFFFF;">DC</span>]]/[[Basic metabolic panel|<span style="color: #FFFFFF;">SMA-7</span>]]/[[LFT|<span style="color: #FFFFFF;">LFT</span>]]/[[PT|<span style="color: #FFFFFF;">PT</span>]]/[[PTT|<span style="color: #FFFFFF;">PTT</span>]]/[[INR|<span style="color: #FFFFFF;">INR</span>]]
+::: ❑&nbsp;&nbsp;Initial dose: 0.5–1.0 μg/min
-❑&nbsp;&nbsp;[[Troponin|<span style="color: #FFFFFF;">Cardiac troponins</span>]], [[CK-MB|<span style="color: #FFFFFF;">CK-MB</span>]]
+::: ❑&nbsp;&nbsp;Maximum dose: 30–40 μg/min
-❑&nbsp;&nbsp;[[Brain natriuretic peptide|<span style="color: #FFFFFF;">BNP</span>]], [[Brain natriuretic peptide|<span style="color: #FFFFFF;">NT-proBNP</span>]]
+::: ❑&nbsp;&nbsp;Titrate to SBP &gt;90 mm Hg
-❑&nbsp;&nbsp;[[Lactate|<span style="color: #FFFFFF;">Lactate</span>]]
+:: ❑&nbsp;&nbsp;[[Dopamine|<span style="color: #000000;">Dopamine</span>]]
-❑&nbsp;&nbsp;[[ECG|<span style="color: #FFFFFF;">12-Lead ECG</span>]]
+::: ❑&nbsp;&nbsp;Cardiac dose: 5.0–10 μg/kg/min
-❑&nbsp;&nbsp;[[CXR|<span style="color: #FFFFFF;">Chest radiograph</span>]]
+::: ❑&nbsp;&nbsp;Pressor dose: 10–20 μg/kg/min
-❑&nbsp;&nbsp;[[Echocardiography|<span style="color: #FFFFFF;">Echocardiography</span>]]</div>}}
+::: ❑&nbsp;&nbsp;Maximum dose: 20–50 μg/kg/min
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A08 | | | | | | | | |A08=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>Cardiogenic shock confirmed</BIG> <br> ''[[{{PAGENAME}}#Criteria for Cardiogenic Shock &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">(click for details on criteria)</span>]]''</div>}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
-{{Family tree|boxstyle=text-align: center; font-size: 90%; padding: 0px;| A09 | | | | | | | | |A09=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''[[{{PAGENAME}}#Hemodynamic Optimization|<span style="color: #FFFFFF;">Hemodynamic optimization</span>]]'''</BIG></div>}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A10 | | | | | | | | |A10=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''''[[{{PAGENAME}}#Preload &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Preload (click for details)</span>]]'''''</BIG>
-❑&nbsp;&nbsp;'''Goal: [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 15–18 mm Hg, [[CVP|<span style="color: #FFFFFF;">CVP</span>]] 8–12 cm H<sub>2</sub>O'''
+:: ❑&nbsp;&nbsp;[[Phenylephrine|<span style="color: #000000;">Phenylephrine</span>]]
-❑&nbsp;&nbsp;'''[[{{PAGENAME}}#Fluid Challenge Protocol|<span style="color: #FFFFFF;">Fluid challenge protocol</span>]]'''
+::: ❑&nbsp;&nbsp;Initial dose: 100–180 μg/min
-❑&nbsp;&nbsp;'''± Correct [[pulmonary congestion|<span style="color: #FFFFFF;">pulmonary congestion</span>]]'''
+::: ❑&nbsp;&nbsp;Maintenance dose: 40–60 μg/min
-: ❑&nbsp;&nbsp;± [[Furosemide|<span style="color: #FFFFFF;">Furosemide</span>]] 40 mg slow IV injection
+:: ❑&nbsp;&nbsp;± [[vasopressin|<span style="color: #000000;">Vasopressin</span>]]
-: ❑&nbsp;&nbsp;± [[Morphine|<span style="color: #FFFFFF;">Morphine</span>]] 2–4 mg slow IV injection
+::: ❑&nbsp;&nbsp;Adjunctive therapy to norepinephrine or dopamine
-</div>}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A11 | | | | | | | | |A11=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''''[[{{PAGENAME}}#Afterload &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Afterload (click for details)</span>]]'''''</BIG>
-❑&nbsp;&nbsp;'''Goal: [[MAP|<span style="color: #FFFFFF;">MAP</span>]] &gt;60 mm Hg, [[SVR|<span style="color: #FFFFFF;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>'''
+::: ❑&nbsp;&nbsp;Usual dose: 0.01–0.03 U/min
-: ❑&nbsp;&nbsp;If ↑ MAP & ↑ SVR: wean [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasodilator|<span style="color: #FFFFFF;">vasodilators</span>]]
+::: ❑&nbsp;&nbsp;Maximum dose: 0.04 U/min
-: ❑&nbsp;&nbsp;If ↓ MAP & ↑ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] + [[inotrope|<span style="color: #FFFFFF;">inotropes</span>]]
+❑&nbsp;&nbsp;'''If ↓ MAP & ↑ SVR:'''
-: ❑&nbsp;&nbsp;If ↓ MAP & ↓ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasopressin|<span style="color: #FFFFFF;">vasopressin</span>]]
+: ❑&nbsp;&nbsp;Continue [[vasopressor|<span style="color: #000000;">vasopressor</span>]]
-</div>}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| A12 | | | | | | | | |A12=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''''[[{{PAGENAME}}#Cardiac Index &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">Cardiac index (click for details)</span>]]'''''</BIG>
-❑&nbsp;&nbsp;'''Goal: [[CI|<span style="color: #FFFFFF;">CI</span>]] &gt;2.2 L/min/m<sup>2</sup>'''
+: ❑&nbsp;&nbsp;Optimize cardiac output with [[inotrope|<span style="color: #000000;">inotropic agent</span>]]</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | | | | | A12 | | | | | | | | |A12=<div style="background: #FEDAEC; color: #000000; padding: 15px;"><BIG>'''''[[{{PAGENAME}}#Cardiac Output Optimization|<span style="color: #000000;">Cardiac index</span>]]'''''</BIG>
-: ❑&nbsp;&nbsp;± [[Dobutamine|<span style="color: #FFFFFF;">Dobutamine</span>]]
+'''Goal: [[CI|<span style="color: #000000;">CI</span>]] &gt;2.2 L/min/m<sup>2</sup>'''
-: ❑&nbsp;&nbsp;± [[Milrinone|<span style="color: #FFFFFF;">Milrinone</span>]]
+❑&nbsp;&nbsp;[[Dobutamine|<span style="color: #000000;">Dobutamine</span>]]
-: ❑&nbsp;&nbsp;± [[IABP|<span style="color: #FFFFFF;">IABP</span>]], [[VAD|<span style="color: #FFFFFF;">VAD</span>]], or [[ECMO|<span style="color: #FFFFFF;">ECMO</span>]] if refractory</div>}}
+: ❑&nbsp;&nbsp;Usual dose: 2.0–20 μg/kg/min
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A13 | | | | | | | | |A13=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate goals'''</BIG>
-❑&nbsp;&nbsp;[[SaO2|<span style="color: #FFFFFF;">SaO2</span>]] &gt;90%–92%
+: ❑&nbsp;&nbsp;Maximum dose: 40 μg/kg/min
-❑&nbsp;&nbsp;[[mixed venous oxygen saturation|<span style="color: #FFFFFF;">MVO2</span>]] &gt;60%
+: ❑&nbsp;&nbsp;Avoid ↑ HR by >10% of baseline
-❑&nbsp;&nbsp;[[SCVO2|<span style="color: #FFFFFF;">ScvO2</span>]] &gt;70%
+❑&nbsp;&nbsp;[[Milrinone|<span style="color: #000000;">Milrinone</span>]]
-❑&nbsp;&nbsp;[[urine output|<span style="color: #FFFFFF;">Urine output</span>]] &gt;0.5 mL/kg/h
+: ❑&nbsp;&nbsp;Loading dose: 50 μg/kg (slowly over 10 minutes)
-❑&nbsp;&nbsp;[[Lactate|<span style="color: #FFFFFF;">Lactate</span>]] &lt;2.2 mM/L
+: ❑&nbsp;&nbsp;Maintenance dose: 0.375–0.75 μg/kg/min</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | | | | | |!| | | | | | | | | |}}
+{{Family tree|boxstyle=text-align: center; font-size: 90%; padding: 0px;| | | | | | | | A13 | | | | | | | | |A13=<div style="background: #FEDAEC; color: #000000; padding: 5px;"><BIG>'''Evaluate perfusion and oxygenation'''</BIG></div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | | | | | A14 | | | | | | | | |A14=<div style="background: #FEDAEC; color: #000000; padding: 15px;"><BIG>'''''Endpoints:'''''</BIG>
-❑&nbsp;&nbsp;[[Hemoglobin|<span style="color: #FFFFFF;">Hemoglobin</span>]] &gt;7–9 g/dL
+❑&nbsp;&nbsp;[[SaO2|<span style="color: #000000;">SaO2</span>]] &gt;92%
-❑&nbsp;&nbsp;± Correct [[arrhythmia|<span style="color: #FFFFFF;">arrhythmia</span>]]
+❑&nbsp;&nbsp;[[mixed venous oxygen saturation|<span style="color: #000000;">SvO2</span>]] &gt;60%
-❑&nbsp;&nbsp;± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">electrolyte disturbance</span>]]</div>}}
+❑&nbsp;&nbsp;[[SCVO2|<span style="color: #000000;">ScvO2</span>]] &gt;70%
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FA8072;| A14 |-| A15 | | | | | |A14=<div style="background: #FA8072; color: #F8F8FF; padding: 16px;">'''Acute myocardial infarction likely?''' [[{{PAGENAME}}#Criteria for Acute Myocardial Infarction &#91;Return to FIRE&#93;|<span style="color: #FFFFFF;">'''''(click for details)'''''</span>]]
-❑&nbsp;&nbsp;[[cardiac biomarkers|<span style="color: #FFFFFF;">Positive cardiac biomarkers (cTnT, cTnI, or CK-MB)</span>]]
+❑&nbsp;&nbsp;[[urine output|<span style="color: #000000;">Urine output</span>]] &gt;0.5 mL/kg/h
-❑&nbsp;&nbsp;Symptoms of myocaridal ischemia
+❑&nbsp;&nbsp;[[Lactate|<span style="color: #000000;">Lactate</span>]] &lt;2.2 mM/L
-❑&nbsp;&nbsp;New significant ECG findings of myocardial ischemia
+❑&nbsp;&nbsp;[[Hematocrit|<span style="color: #000000;">Hematocrit</span>]] ≥30%</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; border-top: 0px;| | | | | | | | A14 | | | | | | | | |A14=<div style="background: #FEDAEC; color: #000000; padding: 15px;"><BIG>'''''If hypoperfusion persists:'''''</BIG><BR>❑&nbsp;&nbsp;Consider [[IABP|<span style="color: #000000;">IABP</span>]], [[VAD|<span style="color: #000000;">VAD</span>]], or [[ECMO|<span style="color: #000000;">ECMO</span>]] if indicated</div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | | | | | |!| | | | | | | | | |}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| | | | | | | | A17 | | | | | | | | |A17=<div style="text-align: center; background: #FEDAEC; color: #000000; font-weight: bold; padding: 15px;"><BIG>Proceed to <br> [[{{PAGENAME}}#Complete Diagnostic Approach xx|<span style="color: #000000;">complete diagnostic approach</span>]]</BIG></div>}}
+{{Family tree/end}}
 </div>
-|A15=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 20px;"><BIG>'''YES, then manage as <br> UA/NSTEMI <br> and proceed to <br> [[{{PAGENAME}}#Acute Ischemia Pathway|<span style="color: #FFFFFF;">acute ischemia pathway</span>]]'''</BIG></div>}}
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
+==Emergency Revascularization <SMALL><SMALL>'''[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]'''</SMALL></SMALL>==
-{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A14 | | | | | | | | |A14=<div style="text-align: center; background: #FA8072; color: #FFFFFF; font-weight: bold; padding: 15px;"><BIG>No, then proceed to <br> [[{{PAGENAME}}#Complete Diagnostic Approach|<span style="color: #FFFFFF;">complete diagnostic approach</span>]]</BIG></div>}}
+<div style="font-size: 80%;">
+{{Family tree/start}}
+{{Family tree|boxstyle=width: 400px; text-align: left; font-size: 90%; padding: 0px;| | | | | | | | B01 | | | |B01=<div style="text-align: center; background: #FEDAEC; color: #000000; padding: 5px; font-weight: bold;"><BIG>'''Acute coronary syndrome'''</BIG><BR>''[[{{PAGENAME}}#Criteria for Acute Myocardial Infarction|<span style="color: #000000;">(click for details on criteria)</span>]]''</div>}}
+{{Family tree|boxstyle=text-align: left; background: #FEDAEC; font-size: 90%; padding: 15px; border-top: 0px;| | | | | | | | B02 | | | | | | | | |B02=<div style="color: #000000">❑&nbsp;&nbsp;'''New ischemic ECG changes'''
+: ❑&nbsp;&nbsp;New or presumably new ST elevation at the J point in two contiguous leads with the cutoff points:
+:: ❑&nbsp;&nbsp;≥0.1 mV in all leads other than leads V<sub>2</sub>–V<sub>3</sub>
+:: ❑&nbsp;&nbsp;≥0.15 mV in women in leads V<sub>2</sub>–V<sub>3</sub>
+:: ❑&nbsp;&nbsp;≥0.2 mV in men ≥40 years in leads V<sub>2</sub>–V<sub>3</sub>
+:: ❑&nbsp;&nbsp;≥0.25 mV in men &lt;40 years in leads V<sub>2</sub>–V<sub>3</sub>
+: ❑&nbsp;&nbsp;New left bundle branch block
+:: ❑&nbsp;&nbsp;QRS duration ≥120 ms
+:: ❑&nbsp;&nbsp;Supraventricular rhythm
+:: ❑&nbsp;&nbsp;Absence of WPW pattern
+:: ❑&nbsp;&nbsp;Broad and notched or slurred R in I and V<sub>5</sub> or V<sub>6</sub>
+:: ❑&nbsp;&nbsp;Absence of Q wave in I and V<sub>5</sub> and V<sub>6</sub>
+:: ❑&nbsp;&nbsp;R peak times ≥60 ms  in V<sub>5</sub> or V<sub>6</sub>
+: ❑&nbsp;&nbsp;New or presumably new ST-segment–T wave changes
+:: ❑&nbsp;&nbsp;Horizontal or down-sloping ST depression ≥0.05 mV in two contiguous leads
+:: ❑&nbsp;&nbsp;T inversion ≥0.1 mV in two contiguous leads with prominent R wave or R/S ratio &gt;1
+❑&nbsp;&nbsp;'''Positive [[cardiac biomarkers|<span style="color: #000000;">cardiac biomarkers</span>]] (cTnT, cTnI, or CK-MB)'''
+❑&nbsp;&nbsp;'''Anginal pain'''
+<table style="border: 2px solid #DCDCDC; font-size: 80%; background: #F8F8FF;">
+<caption> <i>ST elevation in contiguous leads and location of MI and coronary occlusion</i>
+</caption>
+<tr>
+<td align="center" style="background: #A8A8A8; width: 120px;"> <b>ECG Leads with STE</b>
+</td>
+<td align="center" style="background: #A8A8A8; width: 100px;"> <b>Location of MI</b>
+</td>
+<td align="center" style="background: #A8A8A8; width: 200px;"> <b>Location of Coronary Occlusion</b>
+</td></tr>
+<tr>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> I, aVL
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> Lateral, Apical
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> Diagonal, Obtuse Marginal, Distal LAD
+</td></tr>
+<tr>
+<td style="padding: 0 5px; background: #F5F5F5;" align="left"> II, III, aVF
+</td>
+<td style="padding: 0 5px; background: #F5F5F5;" align="left"> Inferior
+</td>
+<td style="padding: 0 5px; background: #F5F5F5;" align="left"> PDA, Wraparound LAD
+</td></tr>
+<tr>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> V<sub>1</sub>, V<sub>2</sub>
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> Septal
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> Proximal LAD, Septal Perforators
+</td></tr>
+<tr>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> V<sub>3</sub>, V<sub>4</sub>
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> Anterior
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> Proximal or Mid LAD, Diagonal
+</td></tr>
+<tr>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> V<sub>5</sub>, V<sub>6</sub>
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> Lateral, Apical
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> Diagonal, Obtuse Marginal, Distal LAD
+</td></tr>
+<tr>
+<td style="padding: 0 5px; background: #F5F5F5;" align="left"> V<sub>7</sub>, V<sub>8</sub>, V<sub>9</sub>
+</td>
+<td style="padding: 0 5px; background: #F5F5F5;" align="left"> Posterobasal
+</td>
+<td style="padding: 0 5px; background: #F5F5F5;" align="left"> LCx, RCA
+</td></tr>
+<tr>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> V<sub>3</sub>R, V<sub>4</sub>R
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> RV Free Wall
+</td>
+<td style="padding: 0 5px; background: #DCDCDC;" align="left"> Proximal RCA
+</td></tr></table></div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%;| | | | |,|-|-|-|^|-|-|-|.| |}}
+{{Family tree|boxstyle=text-align: center; font-size: 90%; padding: 5px; background: #FEDAEC; font-weight: bold;| | | | B03 | | | | | | B04 |B03=<div style="color: #000000; padding: 5px;"><BIG>STEMI</BIG></div>|B04=<div style="color: #000000; padding: 5px;"><BIG>UA/NSTEMI</BIG></div>}}
+{{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px; background: #FEDAEC; border-top: 0px;| | | | B05 | | | | | | B06 |B05=<div style="color: #000000; padding: 15px;"></div>|B06=<div style="color: #000000; padding: 15px;"></div>}}
 {{Family tree/end}}
+</div>
+==Complete Diagnostic Approach <SMALL><SMALL>'''[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]'''</SMALL></SMALL>==
-==Do's==
-===Criteria for Cardiogenic Shock <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]</SMALL></SMALL>===
+==Diagnostic Criteria <SMALL><SMALL>'''[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]'''</SMALL></SMALL>==
+<div class="mw-collapsible mw-collapsed">
+===Criteria for Cardiogenic Shock===
+<div class="mw-collapsible-content">
 * ''Clinical Criteria''<ref name="Califf-1994">{{Cite journal  | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref><ref name="Hollenberg-1999">{{Cite journal  | last1 = Hollenberg | first1 = SM. | last2 = Kavinsky | first2 = CJ. | last3 = Parrillo | first3 = JE. | title = Cardiogenic shock. | journal = Ann Intern Med | volume = 131 | issue = 1 | pages = 47-59 | month = Jul | year = 1999 | doi =  | PMID = 10391815 }}</ref><ref name="Goldberg-1991">{{Cite journal  | last1 = Goldberg | first1 = RJ. | last2 = Gore | first2 = JM. | last3 = Alpert | first3 = JS. | last4 = Osganian | first4 = V. | last5 = de Groot | first5 = J. | last6 = Bade | first6 = J. | last7 = Chen | first7 = Z. | last8 = Frid | first8 = D. | last9 = Dalen | first9 = JE. | title = Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. | journal = N Engl J Med | volume = 325 | issue = 16 | pages = 1117-22 | month = Oct | year = 1991 | doi = 10.1056/NEJM199110173251601 | PMID = 1891019 }}</ref>
 :* Sustained [[hypotension]] ([[systolic blood pressure|SBP]] &lt;90 mm Hg or [[mean arterial pressure|MAP]] 30 mm Hg below baseline in preexisting [[hypertension]] for at least 30 minutes)
 :* Evidence of [[hypoperfusion|tissue hypoperfusion]] (such as [[oliguria]], [[cyanosis]], [[cool extremities]], and [[Altered mental status|altered mental status]])
@@ Line 192: / Line 470: @@
 * ''Hemodynamic Criteria''<ref name="Califf-1994">{{Cite journal  | last1 = Califf | first1 = RM. | last2 = Bengtson | first2 = JR. | title = Cardiogenic shock. | journal = N Engl J Med | volume = 330 | issue = 24 | pages = 1724-30 | month = Jun | year = 1994 | doi = 10.1056/NEJM199406163302406 | PMID = 8190135 }}</ref><ref name="Goldberg-1991">{{Cite journal  | last1 = Goldberg | first1 = RJ. | last2 = Gore | first2 = JM. | last3 = Alpert | first3 = JS. | last4 = Osganian | first4 = V. | last5 = de Groot | first5 = J. | last6 = Bade | first6 = J. | last7 = Chen | first7 = Z. | last8 = Frid | first8 = D. | last9 = Dalen | first9 = JE. | title = Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988. | journal = N Engl J Med | volume = 325 | issue = 16 | pages = 1117-22 | month = Oct | year = 1991 | doi = 10.1056/NEJM199110173251601 | PMID = 1891019 }}</ref><ref name="Forrester-1976">{{Cite journal  | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref><ref name="Forrester-1976-2">{{Cite journal  | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). | journal = N Engl J Med | volume = 295 | issue = 25 | pages = 1404-13 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612162952505 | PMID = 790194 }}</ref><ref name="Reynolds-2008">{{Cite journal  | last1 = Reynolds | first1 = HR. | last2 = Hochman | first2 = JS. | title = Cardiogenic shock: current concepts and improving outcomes. | journal = Circulation | volume = 117 | issue = 5 | pages = 686-97 | month = Feb | year = 2008 | doi = 10.1161/CIRCULATIONAHA.106.613596 | PMID = 18250279 }}</ref>
 :* Sustained [[hypotension]] ([[systolic blood pressure|SBP]]  &lt;90 mm Hg or [[mean arterial pressure|MAP]] 30 mm Hg below baseline in preexisting [[hypertension]] for at least 30 minutes)
 :* Depressed [[cardiac index]] (&lt;1.8 L/min/m<sup>2</sup> of [[body surface area|BSA]] without support or &lt;2.0–2.2 L/min/m<sup>2</sup> of [[body surface area|BSA]] with support) in the presence of an elevated [[PCWP|wedge pressure]] (&gt;15 mm Hg).
@@ Line 200: / Line 477: @@
 -->
-===Hemodynamic Optimization===
+</div></div>
-====Preload <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]</SMALL></SMALL>====
+<div class="mw-collapsible mw-collapsed">
-* Preload manipulation includes quantitative assessment of response to fluid challenge protocol, maintenance of [[PCWP]] and [[CVP]] levels, and minimize or correct [[pulmonary congestion]].<ref name="Forrester-1976">{{Cite journal  | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref><ref name="Forrester-1976-2">{{Cite journal  | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). | journal = N Engl J Med | volume = 295 | issue = 25 | pages = 1404-13 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612162952505 | PMID = 790194 }}</ref><ref name="Reynolds-2008">{{Cite journal  | last1 = Reynolds | first1 = HR. | last2 = Hochman | first2 = JS. | title = Cardiogenic shock: current concepts and improving outcomes. | journal = Circulation | volume = 117 | issue = 5 | pages = 686-97 | month = Feb | year = 2008 | doi = 10.1161/CIRCULATIONAHA.106.613596 | PMID = 18250279 }}</ref><ref name="Crexells-1973">{{Cite journal  | last1 = Crexells | first1 = C. | last2 = Chatterjee | first2 = K. | last3 = Forrester | first3 = JS. | last4 = Dikshit | first4 = K. | last5 = Swan | first5 = HJ. | title = Optimal level of filling pressure in the left side of the heart in acute myocardial infarction. | journal = N Engl J Med | volume = 289 | issue = 24 | pages = 1263-6 | month = Dec | year = 1973 | doi = 10.1056/NEJM197312132892401 | PMID = 4749545 }}</ref>
+===Criteria for Acute Myocardial Infarction===
-======Fluid Challenge Protocol<SMALL><SMALL><ref name="Weil-fluid">{{Cite journal  | last1 = Weil | first1 = MH. | last2 = Henning | first2 = RJ. | title = New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture. | journal = Anesth Analg | volume = 58 | issue = 2 | pages = 124-32 | month =  | year =  | doi =  | PMID = 571235 }}</ref></SMALL></SMALL>======
+<div class="mw-collapsible-content">
+The term acute myocardial infarction (MI) should be used when there is evidence of myocardial necrosis in a clinical setting consistent with acute myocardial ischemia. Under these conditions any one of the following criteria meets the diagnosis for MI:
-* 1. Type of fluid
+* '''Detection of a rise and/or fall of [[cardiac biomarker]] values (preferably [[cardiac troponin]]) with at least one value above the 99<sup>th</sup> percentile upper reference limit (URL)''' and with at least one of the following:<ref name="Thygesen-2012">{{Cite journal  | last1 = Thygesen | first1 = K. | last2 = Alpert | first2 = JS. | last3 = Jaffe | first3 = AS. | last4 = Simoons | first4 = ML. | last5 = Chaitman | first5 = BR. | last6 = White | first6 = HD. | last7 = Thygesen | first7 = K. | last8 = Alpert | first8 = JS. | last9 = White | first9 = HD. | title = Third universal definition of myocardial infarction. | journal = J Am Coll Cardiol | volume = 60 | issue = 16 | pages = 1581-98 | month = Oct | year = 2012 | doi = 10.1016/j.jacc.2012.08.001 | PMID = 22958960 }}</ref>
-:* The choice of crystalloid or colloid solution should be made on the basis of the underlying disease, the nature of fluid deficit, the severity of circulatory failure, the serum albumin concentration, and the risk of bleeding.
+:* '''Symptoms of [[ischemia]]'''<ref name="Braunwald-2000">{{Cite journal  | last1 = Braunwald | first1 = E. | last2 = Antman | first2 = EM. | last3 = Beasley | first3 = JW. | last4 = Califf | first4 = RM. | last5 = Cheitlin | first5 = MD. | last6 = Hochman | first6 = JS. | last7 = Jones | first7 = RH. | last8 = Kereiakes | first8 = D. | last9 = Kupersmith | first9 = J. | title = ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). | journal = J Am Coll Cardiol | volume = 36 | issue = 3 | pages = 970-1062 | month = Sep | year = 2000 | doi =  | PMID = 10987629 }}</ref><ref name="Anderson-2011">{{Cite journal  | last1 = Anderson | first1 = JL. | last2 = Adams | first2 = CD. | last3 = Antman | first3 = EM. | last4 = Bridges | first4 = CR. | last5 = Califf | first5 = RM. | last6 = Casey | first6 = DE. | last7 = Chavey | first7 = WE. | last8 = Fesmire | first8 = FM. | last9 = Hochman | first9 = JS. | title = 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal = Circulation | volume = 123 | issue = 18 | pages = e426-579 | month = May | year = 2011 | doi = 10.1161/CIR.0b013e318212bb8b | PMID = 21444888 }}</ref><ref name="Gibbons-2003">{{Cite journal  | last1 = Gibbons | first1 = RJ. | last2 = Abrams | first2 = J. | last3 = Chatterjee | first3 = K. | last4 = Daley | first4 = J. | last5 = Deedwania | first5 = PC. | last6 = Douglas | first6 = JS. | last7 = Ferguson | first7 = TB. | last8 = Fihn | first8 = SD. | last9 = Fraker | first9 = TD. | title = ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). | journal = Circulation | volume = 107 | issue = 1 | pages = 149-58 | month = Jan | year = 2003 | doi =  | PMID = 12515758 }}</ref>
+::* Recent episode of typical ischemic discomfort that either is of new onset or is severe or that exhibits an accelerating pattern of previous stable angina (especially if it has occurred at rest or is within 2 weeks of a previously documented MI)
+::* ''Quality:'' squeezing, grip-like, pressure-like, suffocating, crushing, or heavy
+::* ''Location:'' diffuse, not localized, nor positional, nor affected by movement at substernal area ± radiation to the neck, jaw, epigastrium, shoulders, or arms
+::* ''Duration:'' usually &gt;20 minutes
+::* ''Factors that provoke the pain:'' exertion or emotional stress
+::* ''Factors that relieve the pain:'' rest or sublingual nitroglycerin (usually within minutes)
+::* ''Accompanying symptoms:'' diaphoresis, nausea or syncope
+:* '''New or presumably new significant [[ST-segment]]–[[T wave]] changes or new [[LBBB|left bundle branch block (LBBB)]].'''
+:* '''Development of [[Pathologic Q Waves|pathological Q waves]] in the [[ECG]].'''
+:* '''Imaging evidence of new loss of viable [[myocardium]] or new regional wall motion abnormality.'''
+:* '''Identification of an intracoronary [[thrombus]] by [[angiography]] or [[autopsy]].'''
-* 2. Rate of infusion
+* Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes or new LBBB, but death occurred before cardiac biomarkers were obtained, or before cardiac biomarker values would be increased.
-:* Based on the baseline of central venous pressure or pulmonary capillary wedge pressure, a volume of 50, 100, or 200 ml of fluid is administered over a 10-minute interval through a peripheral venous catheter.
-:*
-* 3. Clinical end points
+* Percutaneous coronary intervention related MI is arbitrarily defined by elevation of cardiac troponin (cTn) values (>5 × 99<sup>th</sup> percentile URL) in patients with normal baseline values (≤99<sup>th</sup> percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, either one of the followings is required:
-::* Fluid challenge with predetermined boluses should be titrated to reach hemodynamic and clinical endpoints.
+:* Symptoms suggestive of myocardial ischemia
-::* Vasopressors, inotropes, mechanical circulatory assistance, or ECMO may be considered if end-organ hypoperfusion persists despite adequate ventricular filling pressure.
+:* New ischemic ECG changes
+:* Angiographic findings consistent with a procedural complication
+:* Imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality
-* 4. Pressure safety limits
+* Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac biomarker values with at least one value above the 99<sup>th</sup> percentile URL.
+* Coronary artery bypass grafting related MI is arbitrarily defined by elevation of cardiac biomarker values (>10 × 99<sup>th</sup> percentile URL) in patients with normal baseline cTn values (≤99<sup>th</sup> percentile URL). In addition, either one of the followings is required:
+:* New pathological Q waves or new LBBB
+:* Angiographic documented new graft or new native coronary artery occlusion
+:* Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
+</div></div>
+==Maintenance of Blood Pressure <SMALL><SMALL>'''[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]'''</SMALL></SMALL>==
-* [[Norepinephrine]]<ref name="NOREPINEPHRINE BITARTRATE INJECTION">{{Cite web  | last =  | first =  | title = NOREPINEPHRINE BITARTRATE INJECTION | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3352c7d0-e621-46ed-9a54-e4a9583cde10 | publisher =  | date =  | accessdate = }}</ref><ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref>
+<div class="mw-collapsible mw-collapsed">
-:* ''Dosage and Administration''
-::* Mix 1 ampule (4 mg) of [[norepinephrine]] in 250 mL of [[Intravenous sugar solution|D5W]] or [[Intravenous sugar solution|D5NS]]. Avoid dilution in [[normal saline]] alone.
+======Norepinephrine======
-::* Initial dose: 0.5–1.0 μg/min [[IV|IV infusion]]; titrate to maintain [[SBP]] at above 90 mm Hg (up to 30–40 μg/min).
-<!--
+<div class="mw-collapsible-content">
-:* ''Indications''
-::* [[Blood pressure]] control in certain acute [[hypotensive]] states (e.g., [[pheochromocytoma|pheochromocytomectomy]], [[sympathectomy]], [[poliomyelitis]], [[spinal anesthesia]], [[myocardial infarction]], [[septicemia]], [[transfusion|blood transfusion]], and [[drug reaction]]s).
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="NOREPINEPHRINE BITARTRATE INJECTION">{{Cite web  | last =  | first =  | title = NOREPINEPHRINE BITARTRATE INJECTION | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3352c7d0-e621-46ed-9a54-e4a9583cde10 | publisher =  | date =  | accessdate = }}</ref>
-::* Adjunct in the treatment of [[cardiac arrest]] and profound [[hypotension]].
+:* Suggested Dilution:
--->
+::* Mix 4 mg of [[norepinephrine]] in 250 mL of [[Intravenous sugar solution|D5W]] or [[Intravenous sugar solution|D5NS]]. Avoid dilution in [[normal saline]] alone.
-:* ''Contraindications''
+:* Suggested Regimen:
-::* [[Norepinephrine]] should not be given to patients who are [[hypotensive]] from [[hypovolemia|blood volume deficits]] except as an emergency measure to maintain [[coronary]] and [[cerebral]] artery [[perfusion]] until blood volume replacement therapy can be completed.
+::* Start at a dose of 0.5–1.0 μg/min [[IV|IV infusion]]; titrate to maintain [[SBP]] at above 90 mm Hg (up to 30–40 μg/min).
-::* [[Norepinephrine]] should also not be given to patients with [[mesentery|mesenteric]] or peripheral vascular [[thrombosis]] unless it is necessary as a life-saving procedure.
+* Contraindications
+:* [[Norepinephrine]] should not be given to patients who are [[hypotensive]] from [[hypovolemia|blood volume deficits]] except as an emergency measure to maintain [[coronary]] and [[cerebral]] artery [[perfusion]] until blood volume replacement therapy can be completed.
+:* [[Norepinephrine]] should also not be given to patients with [[mesentery|mesenteric]] or peripheral vascular [[thrombosis]] unless it is necessary as a life-saving procedure.
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Dopamine======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="DOPAMINE HCL injection, solution">{{Cite web  | last =  | first =  | title = DOPAMINE HCL INJECTION, SOLUTION [AMERICAN REGENT, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=e061fb3e-afd7-4188-b5fb-617ac1d3e38d | publisher =  | date =  | accessdate = }}</ref>
+:* Suggested Dilution: transfer contents of one or more ampuls or vials by aseptic technique to either 250 mL or 500 mL of one of the following sterile intravenous solutions
+::* Sodium Chloride Injection
+::* Dextrose (5%) Injection
+::* Dextrose (5%) and Sodium Chloride (0.9%) Injection
+::* 5% Dextrose in 0.45% Sodium Chloride Solution
+::* Dextrose (5%) in Lactated Ringer’s Solution
+::* Sodium Lactate (1/6 Molar) Injection
+::* Lactated Ringer’s Injection
+:* Suggested Regimen:
+::* Begin administration of diluted solution at doses of 2–5 μg/kg/minute in patients who are likely to respond to modest increments of heart force and renal perfusion.
+::* In more seriously ill patients, begin administration of diluted solution at doses of 5 μg/kg/minute and increase gradually, using 5–10 μg/kg/minute increments, up to 20–50 μg/kg/minute as needed.
+::* If doses of 50 μg/kg/minute are required, it is suggested that urine output be checked frequently. Should the urine flow begin to decrease in the absence of hypotension, reduction of dosage should be considered.
+::* Treatment of all patients requires constant evaluation of therapy in terms of the blood volume, augmentation of myocardial contractility, and distribution of peripheral perfusion. Dosage should be adjusted according to the patient’s response, with particular attention to diminution of established urine flow rate, increasing tachycardia or development of new dysrhythmias as indices for decreasing or temporarily suspending the dosage.
+* Contraindications
+:* Pheochromocytoma
+:* Uncorrected tachyarrhythmias or ventricular fibrillation
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Dobutamine======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="DOBUTAMINE (DOBUTAMINE HYDROCHLORIDE) INJECTION, SOLUTION">{{Cite web  | last =  | first =  | title = DOBUTAMINE (DOBUTAMINE HYDROCHLORIDE) INJECTION, SOLUTION [HOSPIRA, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=cb842dc2-fb15-48f9-e4b1-ea4280db0199 | publisher =  | date =  | accessdate = }}</ref>
+:* Suggested Dilution: dobutamine injection must be further diluted in an IV container. Dilute 20 mL of dobutamine in at least 50 mL of diluent and dilute 40 mL of dobutamine in at least 100 mL of diluent. Use one of the following intravenous solutions as a diluent:
+::* Dextrose Injection 5%
+::* Dextrose 5% and Sodium Chloride 0.45% Injection
+::* Dextrose 5% and Sodium Chloride 0.9% Injection
+::* Dextrose Injection 10%, Isolyte® M with 5% Dextrose Injection
+::* Lactated Ringer’s Injection
+::* 5% Dextrose in Lactated Ringer’s Injection
+::* Normosol®-M in D5-W
+::* 20% Osmitrol® in Water for Injection
+::* Sodium Chloride Injection 0.9%
+::* Sodium Lactate Injection
+:* Suggested Regimen:
+::* The rate of infusion needed to increase cardiac output usually ranged from 2.5 to 15 mcg/kg/min.
+::* On rare occasions, infusion rates up to 40 mcg/kg/min have been required to obtain the desired effect.
+* Contraindications
+:* Idiopathic hypertrophic subaortic stenosis
+:* Hypersensitivity to dobutamine
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Nitroglycerin======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="NITROGLYCERIN INJECTION, SOLUTION">{{Cite web  | last =  | first =  | title = NITROGLYCERIN INJECTION, SOLUTION [AMERICAN REGENT, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=8c52cdf6-87be-4719-b105-f08be096d462 | publisher =  | date =  | accessdate = }}</ref>
+:* Suggested Initial Dilution:
+::* Nitroglycerin must be diluted in dextrose (5%) injection or sodium chloride (0.9%) injection prior to its infusion. Transfer 50 mg of nitroglycerin into a 500 mL glass bottle of either dextrose (5%) injection or sodium chloride injection (0.9%). This yields a final concentration of 100 μg/mL. Diluting 5 mg nitroglycerin into 100 mL will yield a final concentration of 50 μg/mL.
+:* Suggested Maintenance Dilution:
+::* Consider the fluid requirements of the patient as well as the expected duration of infusion in selecting the appropriate dilution of Nitroglycerin Injection.
+::* The concentration of nitroglycerin should not exceed 400 μg/mL.
+:* Suggested Regimen:
+::* '''Severe hypotension and shock may occur with even small doses of nitroglycerin. This drug should therefore be used with caution in patients who may be volume depleted or who, for whatever reason, are already hypotensive. Hypotension induced by nitroglycerin may be accompanied by paradoxical bradycardia and increased angina pectoris.'''
+::* The initial dosage should be 5 μg/min delivered through an infusion pump. Subsequent titration must be adjusted to the clinical situation, with dose increments becoming more cautious as partial response is seen.
+::* Initial titration should be in 5 μg/min increments, with increases every 3–5 minutes until some response is noted.
+::* If no response is seen at 20 μg/min, increments of 10 and later 20 μg/min can be used.
+::* Once a partial blood pressure response is observed, the dose increase should be reduced and the interval between increases should be lengthened.
+* Contraindications
+:* Pericardial tamponade
+:* Restrictive cardiomyopathy
+:* Constrictive pericarditis
+:* Hypersensitivity to nitroglycerin
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Nitroprusside======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="NITROPRESS (SODIUM NITROPRUSSIDE) INJECTION">{{Cite web  | last =  | first =  | title = NITROPRESS (SODIUM NITROPRUSSIDE) INJECTION, SOLUTION, CONCENTRATE [HOSPIRA, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6a44bcac-a0e1-4069-5691-db7b83dbb4b7 | publisher =  | date =  | accessdate = }}</ref><ref name="Chatterjee-1973">{{Cite journal  | last1 = Chatterjee | first1 = K. | last2 = Parmley | first2 = WW. | last3 = Ganz | first3 = W. | last4 = Forrester | first4 = J. | last5 = Walinsky | first5 = P. | last6 = Crexells | first6 = C. | last7 = Swan | first7 = HJ. | title = Hemodynamic and metabolic responses to vasodilator therapy in acute myocardial infarction. | journal = Circulation | volume = 48 | issue = 6 | pages = 1183-93 | month = Dec | year = 1973 | doi =  | PMID = 4762476 }}</ref>
+:* Suggested Dilution:
+::* Depending on the desired concentration, the solution containing 50 mg of nitroprusside must be further diluted in 250–1000 mL of sterile 5% dextrose injection.
+:* Suggested Regimen:
+::* '''While the average effective rate in adult and pediatric patients is about 3 μg/kg/min, some patients will become dangerously hypotensive at this rate.'''
+::* '''Nitroprusside can induce essentially unlimited blood pressure reduction, the blood pressure must be continuously monitored, using either a continually reinflated sphygmomanometer or (preferably) an intra-arterial pressure sensor. Special caution should be used in elderly patients, since they may be more sensitive to the hypotensive effects of the drug.'''
+::* Infusion of sodium nitroprusside should be started at a very low rate (0.3 μg/kg/min), with upward titration every few minutes until the desired effect is achieved or the maximum recommended infusion rate (10 μg/kg/min) has been reached.
+* Contraindications
+:* Sodium nitroprusside should not be used for the treatment of acute congestive heart failure associated with reduced peripheral vascular resistance such as high-output heart failure that may be seen in endotoxic sepsis.
+:* Sodium nitroprusside should not be used in the treatment of compensatory hypertension, where the primary hemodynamic lesion is aortic coarctation or arteriovenous shunting.
+:* Sodium nitroprusside should not be used to produce hypotension during surgery in patients with known inadequate cerebral circulation, or in moribund patients coming to emergency surgery.
+:* Patients with congenital (Leber’s) optic atrophy or with toxic amblyopia have unusually high cyanide/thiocyanate ratios. These rare conditions are probably associated with defective or absent rhodanase, and sodium nitroprusside should be avoided in these patients.
+</div></div>
+==Optimization of Hemodynamic Status <SMALL><SMALL>'''[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]'''</SMALL></SMALL>==
+===Preload Optimization===
+<div class="mw-collapsible mw-collapsed">
+======Fluid Challenge Protocol======
+<div class="mw-collapsible-content">
+* Preload optimization involves scrupulous fluid loading, manipulation of [[PCWP]] and/or [[central venous pressure|CVP]] levels, and correction of [[pulmonary congestion]].<ref name="Forrester-1976">{{Cite journal  | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref><ref name="Forrester-1976-2">{{Cite journal  | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). | journal = N Engl J Med | volume = 295 | issue = 25 | pages = 1404-13 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612162952505 | PMID = 790194 }}</ref><ref name="Reynolds-2008">{{Cite journal  | last1 = Reynolds | first1 = HR. | last2 = Hochman | first2 = JS. | title = Cardiogenic shock: current concepts and improving outcomes. | journal = Circulation | volume = 117 | issue = 5 | pages = 686-97 | month = Feb | year = 2008 | doi = 10.1161/CIRCULATIONAHA.106.613596 | PMID = 18250279 }}</ref><ref name="Crexells-1973">{{Cite journal  | last1 = Crexells | first1 = C. | last2 = Chatterjee | first2 = K. | last3 = Forrester | first3 = JS. | last4 = Dikshit | first4 = K. | last5 = Swan | first5 = HJ. | title = Optimal level of filling pressure in the left side of the heart in acute myocardial infarction. | journal = N Engl J Med | volume = 289 | issue = 24 | pages = 1263-6 | month = Dec | year = 1973 | doi = 10.1056/NEJM197312132892401 | PMID = 4749545 }}</ref>
+* Protocolized fluid administration titrated to hemodynamic and clinical endpoints secures the efficacy of tissue perfusion and oxygenation.<ref name="Weil-fluid1">{{Cite journal  | last1 = Weil | first1 = MH. | last2 = Henning | first2 = RJ. | title = New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture. | journal = Anesth Analg | volume = 58 | issue = 2 | pages = 124-32 | month =  | year =  | doi =  | PMID = 571235 }}</ref>
+* Four elements of the fluid challenge protocol: type of fluid (T), rate of fluid administration (R), objective (O), and limits (L).<ref name="Vincent-2011">{{Cite journal  | last1 = Vincent | first1 = JL. | title = Let's give some fluid and see what happens versus the mini-fluid challenge. | journal = Anesthesiology | volume = 115 | issue = 3 | pages = 455-6 | month = Sep | year = 2011 | doi = 10.1097/ALN.0b013e318229a521 | PMID = 21792055 }}</ref>
+:* 1. Type of fluid (T)
+::* The choice of crystalloid or colloid solution should be made on the basis of the underlying disease, the nature of fluid deficit, the severity of circulatory failure, the serum albumin concentration, and the risk of bleeding.<ref name="Weil-fluid2">{{Cite journal  | last1 = Vincent | first1 = JL. | last2 = Weil | first2 = MH. | title = Fluid challenge revisited. | journal = Crit Care Med | volume = 34 | issue = 5 | pages = 1333-7 | month = May | year = 2006 | doi = 10.1097/01.CCM.0000214677.76535.A5 | PMID = 16557164 }}</ref>
+::* There were no significant differences in mortality between saline and albumin infusion for critically ill patients.<ref name="Finfer-2004">{{Cite journal  | last1 = Finfer | first1 = S. | last2 = Bellomo | first2 = R. | last3 = Boyce | first3 = N. | last4 = French | first4 = J. | last5 = Myburgh | first5 = J. | last6 = Norton | first6 = R. | title = A comparison of albumin and saline for fluid resuscitation in the intensive care unit. | journal = N Engl J Med | volume = 350 | issue = 22 | pages = 2247-56 | month = May | year = 2004 | doi = 10.1056/NEJMoa040232 | PMID = 15163774 }}</ref>
+::* [[Blood transfusion]] may be considered in the presence of profound [[anemia]] or massive [[hemorrhage]].<ref name="Weil-fluid1">{{Cite journal  | last1 = Weil | first1 = MH. | last2 = Henning | first2 = RJ. | title = New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture. | journal = Anesth Analg | volume = 58 | issue = 2 | pages = 124-32 | month =  | year =  | doi =  | PMID = 571235 }}</ref>
+::* [[Hyperchloremic acidosis]] may be associated with the use of isotonic saline solution.<ref name="Scheingraber-1999">{{Cite journal  | last1 = Scheingraber | first1 = S. | last2 = Rehm | first2 = M. | last3 = Sehmisch | first3 = C. | last4 = Finsterer | first4 = U. | title = Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. | journal = Anesthesiology | volume = 90 | issue = 5 | pages = 1265-70 | month = May | year = 1999 | doi =  | PMID = 10319771 }}</ref>
+:* 2. Rate of fluid administration (R)
+::* Based on the level of [[pulmonary capillary wedge pressure]] or [[central venous pressure]], a volume of 50, 100, or 200 ml of fluid is administered over a 10-minute interval through a peripheral venous catheter.<ref name="Weil-fluid1">{{Cite journal  | last1 = Weil | first1 = MH. | last2 = Henning | first2 = RJ. | title = New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture. | journal = Anesth Analg | volume = 58 | issue = 2 | pages = 124-32 | month =  | year =  | doi =  | PMID = 571235 }}</ref>
+{|
+| style="width: 10%" |
+| style="width: 90%" |
+{| style="border: 2px solid #DCDCDC; font-size: 90%;"
+| align="center" style="background: #DCDCDC; width: 150px;" | '''Baseline PCWP (mm Hg)'''
+| align="center" style="background: #DCDCDC; width: 150px;" | '''Baseline CVP (cm H<sub>2</sub>O)'''
+| align="center" style="background: #DCDCDC; width: 300px;" | '''Rate of fluid administration'''
+|-
+| style="padding: 0 5px; background: #F5F5F5;" align=center | ≥16
+| style="padding: 0 5px; background: #F5F5F5;" align=center | ≥14
+| style="padding: 0 5px; background: #F5F5F5;" align=left | 50 mL over 10 minutes
+|-
+| style="padding: 0 5px; background: #F5F5F5;" align=center | &lt;16 but ≥12
+| style="padding: 0 5px; background: #F5F5F5;" align=center | &lt;14 but ≥8
+| style="padding: 0 5px; background: #F5F5F5;" align=left | 100 mL over 10 minutes
+|-
+| style="padding: 0 5px; background: #F5F5F5;" align=center | &lt;12
+| style="padding: 0 5px; background: #F5F5F5;" align=center | &lt;8
+| style="padding: 0 5px; background: #F5F5F5;" align=left | 200 mL over 10 minutes
+|}
+|}
+:* 3. Objective (O)
+::* Fluid administration should be titrated to reach predetermined clinical endpoints such as resolution of tachycardia or oliguria, improved skin perfusion or level of consciousness, normalization of lactate concentrations, and restoration of adequate blood pressure or ventricular filling pressure.<ref name="Weil-fluid2">{{Cite journal  | last1 = Vincent | first1 = JL. | last2 = Weil | first2 = MH. | title = Fluid challenge revisited. | journal = Crit Care Med | volume = 34 | issue = 5 | pages = 1333-7 | month = May | year = 2006 | doi = 10.1097/01.CCM.0000214677.76535.A5 | PMID = 16557164 }}</ref>
+:* 4. Limits (L)
+::* Fluid administration should be stopped if the safety limits are violated to minimize the risk of developing [[pulmonary edema]].
+::* Inotropes, vasodilators, or mechanical circulatory device may be required if signs of hypoperfusion persist despite optimal fluid loading.
+::* Hemodynamic safety limits based on PCWP (the 7–3 rule) or CVP (the 5–2 rule):<ref name="Weil-fluid1">{{Cite journal  | last1 = Weil | first1 = MH. | last2 = Henning | first2 = RJ. | title = New concepts in the diagnosis and fluid treatment of circulatory shock. Thirteenth annual Becton, Dickinson and Company Oscar Schwidetsky Memorial Lecture. | journal = Anesth Analg | volume = 58 | issue = 2 | pages = 124-32 | month =  | year =  | doi =  | PMID = 571235 }}</ref>
+{|
+| style="width: 10%" |
+| style="width: 90%" |
+{| style="border: 2px solid #DCDCDC; font-size: 90%;"
+| align="center" style="background: #DCDCDC; width: 150px;" | '''↑ PCWP (mm Hg)'''
+| align="center" style="background: #DCDCDC; width: 150px;" | '''↑ CVP (cm H<sub>2</sub>O)'''
+| align="center" style="background: #DCDCDC; width: 300px;" | '''Action'''
+|-
+| style="padding: 0 5px; background: #F5F5F5;" align=center | ≥7
+| style="padding: 0 5px; background: #F5F5F5;" align=center | ≥5
+| style="padding: 0 5px; background: #F5F5F5;" align=left | Stop fluid administration
+|-
+| style="padding: 0 5px; background: #F5F5F5;" align=center | &lt;7 but &gt;3
+| style="padding: 0 5px; background: #F5F5F5;" align=center | &lt;5 but &gt;2
+| style="padding: 0 5px; background: #F5F5F5;" align=left | Wait and recheck pressure after 10 minutes
+|-
+| style="padding: 0 5px; background: #F5F5F5;" align=center | ≤3
+| style="padding: 0 5px; background: #F5F5F5;" align=center | ≤2
+| style="padding: 0 5px; background: #F5F5F5;" align=left | Continue fluid administration
+|}
+|}
+</div></div>
+<div class="mw-collapsible mw-collapsed">
 ======Pulmonary Congestion======
-::* Radiologic manifestations of [[pulmonary congestion]] reflect the extent of elevation in [[PCWP|wedge pressure]]:
+<div class="mw-collapsible-content">
-{| style="border: 2px solid #DCDCDC; font-size: 90%;" align=center
+* Findings suggestive of cardiogenic pulmonary edema:<ref name="Ware-2005">{{Cite journal  | last1 = Ware | first1 = LB. | last2 = Matthay | first2 = MA. | title = Clinical practice. Acute pulmonary edema. | journal = N Engl J Med | volume = 353 | issue = 26 | pages = 2788-96 | month = Dec | year = 2005 | doi = 10.1056/NEJMcp052699 | PMID = 16382065 }}</ref>
+:* History and clinical manifestations
+::* Cough
+::* Dyspnea
+::* Expectoration of frothy sputum
+::* Orthopnea
+::* Paroxysmal nocturnal dyspnea
+::* Signs and symptoms of heart failure
+::* Signs and symptoms of hypoxemia
+::* Signs and symptoms of myocardial ischemia
+::* Signs and symptoms of valvular dysfunction
+::* Tachypnea
+:* Physical examination
+::* Cool extremities
+::* Heart murmurs
+::* Hepatomegaly
+::* Inspiratory crackles or rhonchi
+::* Jugular venous distention
+::* S3 gallop
+::* Peripheral edema
+:* Laboratory and hemodynamic findings
+::* BNP > 500 pg/mL
+::* PCWP >18 mm Hg
+:* Radiologic findings
+::* Central infiltrates with peripheral sparing
+::* Cephalization of pulmonary vessels
+::* Enlarged cardiac silhouette
+::* Enlargement of peribronchovascular spaces
+::* Increased opacity of acinar areas that coalesce into frank consolidations
+::* Kerley B lines
+::* Peribronchial cuffing
+::* Pleural effusions
+::* Vascular pedicle width >70 mm
+* Radiologic manifestations of [[pulmonary congestion]] reflect the extent of elevation in [[PCWP|wedge pressure]]:<ref name="Forrester-1976">{{Cite journal  | last1 = Forrester | first1 = JS. | last2 = Diamond | first2 = G. | last3 = Chatterjee | first3 = K. | last4 = Swan | first4 = HJ. | title = Medical therapy of acute myocardial infarction by application of hemodynamic subsets (first of two parts). | journal = N Engl J Med | volume = 295 | issue = 24 | pages = 1356-62 | month = Dec | year = 1976 | doi = 10.1056/NEJM197612092952406 | PMID = 790191 }}</ref>
+{|
+| style="width: 4%" |
+| style="width: 96%" |
+{| style="border: 2px solid #DCDCDC; font-size: 90%;"
 | align="center" style="background: #DCDCDC; width: 100px;"| '''PCWP (mm Hg)'''
 | align="center" style="background: #DCDCDC; width: 200px;" | '''Phase of Pulmonary Congestion'''
@@ Line 263: / Line 781: @@
 | style="padding: 0 5px; background: #F5F5F5;" align=left | Coalescence of periacinar rosettes resulting in "Bat's wing" opacities
 |}
+|}
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Furosemide======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="FUROSEMIDE injection">{{Cite web  | last =  | first =  | title = FUROSEMIDE INJECTION [AMERICAN REGENT, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=2d6a6ff9-3f12-4a6e-bba3-3f85fd54ffac | publisher =  | date =  | accessdate = }}</ref>
+:* For [[pulmonary edema|acute pulmonary edema]], the initial dose is 40 mg injected slowly intravenously (over 1 to 2 minutes).
+:* If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes).
+* Contraindications
+:* [[Anuria]]
+:* [[Hypersensitivity]] to [[furosemide]]
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Morphine======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="MORPHINE SULFATE INJECTION">{{Cite web  | last =  | first =  | title = MORPHINE SULFATE INJECTION, SOLUTION, CONCENTRATE | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=cadc3fdb-8edc-44cd-aaea-89e68aaf9a04 | publisher =  | date =  | accessdate = }}</ref><ref name="O'Connor-2010">{{Cite journal  | last1 = O'Connor | first1 = RE. | last2 = Brady | first2 = W. | last3 = Brooks | first3 = SC. | last4 = Diercks | first4 = D. | last5 = Egan | first5 = J. | last6 = Ghaemmaghami | first6 = C. | last7 = Menon | first7 = V. | last8 = O'Neil | first8 = BJ. | last9 = Travers | first9 = AH. | title = Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S787-817 | month = Nov | year = 2010 | doi = 10.1161/CIRCULATIONAHA.110.971028 | PMID = 20956226 }}</ref>
+:* '''Morphine may cause [[Hypoventilation|respiratory depression]] or exacerbate [[hypotension]] in [[hypovolemia|volume-depleted]] patients.'''
+:* Morphine may be used adjunctively in the treatment of acute pulmonary edema at a dose of 2–4 mg (slow [[IV|IV injection]] over 1–5 minutes) every 5–30 minutes as needed.
+* Contraindications
+:* [[Hypersensitivity]] to [[morphine sulfate]] is one of the contraindications to its use.
+:* [[Morphine]] should not be used in [[convulsion|convulsive states]], such as those occurring in [[status epilepticus]], [[tetanus]], and [[strychnine]] poisoning.
+:* [[Morphine]] is also contraindicated in the following conditions: [[respiratory insufficiency|respiratory insufficiency or depression]]; [[bronchial asthma]]; [[heart failure]] secondary to [[COPD|chronic lung disease]]; [[cardiac arrhythmia]]s; increased [[ICP|intracranial or cerebrospinal pressure]]; [[head injury|head injuries]]; [[brain tumor]]; acute [[alcoholism]]; and [[delirium tremens]].
+</div></div>
+===Afterload Optimization===
+<div class="mw-collapsible mw-collapsed">
+======Nitroglycerin======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="NITROGLYCERIN INJECTION, SOLUTION">{{Cite web  | last =  | first =  | title = NITROGLYCERIN INJECTION, SOLUTION [AMERICAN REGENT, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=8c52cdf6-87be-4719-b105-f08be096d462 | publisher =  | date =  | accessdate = }}</ref>
+:* Suggested Initial Dilution:
+::* Nitroglycerin must be diluted in dextrose (5%) injection or sodium chloride (0.9%) injection prior to its infusion. Transfer 50 mg of nitroglycerin into a 500 mL glass bottle of either dextrose (5%) injection or sodium chloride injection (0.9%). This yields a final concentration of 100 μg/mL. Diluting 5 mg nitroglycerin into 100 mL will yield a final concentration of 50 μg/mL.
+:* Suggested Maintenance Dilution:
+::* Consider the fluid requirements of the patient as well as the expected duration of infusion in selecting the appropriate dilution of Nitroglycerin Injection.
+::* The concentration of nitroglycerin should not exceed 400 μg/mL.
+:* Suggested Regimen:
+::* '''Severe hypotension and shock may occur with even small doses of nitroglycerin. This drug should therefore be used with caution in patients who may be volume depleted or who, for whatever reason, are already hypotensive. Hypotension induced by nitroglycerin may be accompanied by paradoxical bradycardia and increased angina pectoris.'''
+::* The initial dosage should be 5 μg/min delivered through an infusion pump. Subsequent titration must be adjusted to the clinical situation, with dose increments becoming more cautious as partial response is seen.
+::* Initial titration should be in 5 μg/min increments, with increases every 3–5 minutes until some response is noted.
+::* If no response is seen at 20 μg/min, increments of 10 and later 20 μg/min can be used.
+::* Once a partial blood pressure response is observed, the dose increase should be reduced and the interval between increases should be lengthened.
+* Contraindications
+:* Pericardial tamponade
+:* Restrictive cardiomyopathy
+:* Constrictive pericarditis
+:* Hypersensitivity to nitroglycerin
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Nitroprusside======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="NITROPRESS (SODIUM NITROPRUSSIDE) INJECTION">{{Cite web  | last =  | first =  | title = NITROPRESS (SODIUM NITROPRUSSIDE) INJECTION, SOLUTION, CONCENTRATE [HOSPIRA, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6a44bcac-a0e1-4069-5691-db7b83dbb4b7 | publisher =  | date =  | accessdate = }}</ref><ref name="Chatterjee-1973">{{Cite journal  | last1 = Chatterjee | first1 = K. | last2 = Parmley | first2 = WW. | last3 = Ganz | first3 = W. | last4 = Forrester | first4 = J. | last5 = Walinsky | first5 = P. | last6 = Crexells | first6 = C. | last7 = Swan | first7 = HJ. | title = Hemodynamic and metabolic responses to vasodilator therapy in acute myocardial infarction. | journal = Circulation | volume = 48 | issue = 6 | pages = 1183-93 | month = Dec | year = 1973 | doi =  | PMID = 4762476 }}</ref>
+:* Suggested Dilution:
+::* Depending on the desired concentration, the solution containing 50 mg of nitroprusside must be further diluted in 250–1000 mL of sterile 5% dextrose injection.
+:* Suggested Regimen:
+::* '''While the average effective rate in adult and pediatric patients is about 3 μg/kg/min, some patients will become dangerously hypotensive at this rate.'''
+::* '''Nitroprusside can induce essentially unlimited blood pressure reduction, the blood pressure must be continuously monitored, using either a continually reinflated sphygmomanometer or (preferably) an intra-arterial pressure sensor. Special caution should be used in elderly patients, since they may be more sensitive to the hypotensive effects of the drug.'''
+::* Infusion of sodium nitroprusside should be started at a very low rate (0.3 μg/kg/min), with upward titration every few minutes until the desired effect is achieved or the maximum recommended infusion rate (10 μg/kg/min) has been reached.
+* Contraindications
+:* Sodium nitroprusside should not be used for the treatment of acute congestive heart failure associated with reduced peripheral vascular resistance such as high-output heart failure that may be seen in endotoxic sepsis.
+:* Sodium nitroprusside should not be used in the treatment of compensatory hypertension, where the primary hemodynamic lesion is aortic coarctation or arteriovenous shunting.
+:* Sodium nitroprusside should not be used to produce hypotension during surgery in patients with known inadequate cerebral circulation, or in moribund patients coming to emergency surgery.
+:* Patients with congenital (Leber’s) optic atrophy or with toxic amblyopia have unusually high cyanide/thiocyanate ratios. These rare conditions are probably associated with defective or absent rhodanase, and sodium nitroprusside should be avoided in these patients.
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Norepinephrine======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="NOREPINEPHRINE BITARTRATE INJECTION">{{Cite web  | last =  | first =  | title = NOREPINEPHRINE BITARTRATE INJECTION | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3352c7d0-e621-46ed-9a54-e4a9583cde10 | publisher =  | date =  | accessdate = }}</ref>
+:* Suggested Dilution:
+::* Mix 4 mg of [[norepinephrine]] in 250 mL of [[Intravenous sugar solution|D5W]] or [[Intravenous sugar solution|D5NS]]. Avoid dilution in [[normal saline]] alone.
+:* Suggested Regimen:
+::* Start at a dose of 0.5–1.0 μg/min [[IV|IV infusion]]; titrate to maintain [[SBP]] at above 90 mm Hg (up to 30–40 μg/min).
+* Contraindications
+:* [[Norepinephrine]] should not be given to patients who are [[hypotensive]] from [[hypovolemia|blood volume deficits]] except as an emergency measure to maintain [[coronary]] and [[cerebral]] artery [[perfusion]] until blood volume replacement therapy can be completed.
+:* [[Norepinephrine]] should also not be given to patients with [[mesentery|mesenteric]] or peripheral vascular [[thrombosis]] unless it is necessary as a life-saving procedure.
-:* [[Furosemide]]<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="FUROSEMIDE injection">{{Cite web  | last =  | first =  | title = FUROSEMIDE INJECTION [AMERICAN REGENT, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=2d6a6ff9-3f12-4a6e-bba3-3f85fd54ffac | publisher =  | date =  | accessdate = }}</ref>
+</div></div>
-::* ''Dosage and Administration''
-:::* For [[pulmonary edema|acute pulmonary edema]], the initial dose is 40 mg injected slowly intravenously (over 1 to 2 minutes).
-:::* If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes).
-::* ''Contraindications''
-:::* [[Anuria]]
-:::* [[Hypersensitivity]] to [[furosemide]]
-:* [[Morphine]]<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="MORPHINE SULFATE INJECTION">{{Cite web  | last =  | first =  | title = MORPHINE SULFATE INJECTION, SOLUTION, CONCENTRATE | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=cadc3fdb-8edc-44cd-aaea-89e68aaf9a04 | publisher =  | date =  | accessdate = }}</ref><ref name="O'Connor-2010">{{Cite journal  | last1 = O'Connor | first1 = RE. | last2 = Brady | first2 = W. | last3 = Brooks | first3 = SC. | last4 = Diercks | first4 = D. | last5 = Egan | first5 = J. | last6 = Ghaemmaghami | first6 = C. | last7 = Menon | first7 = V. | last8 = O'Neil | first8 = BJ. | last9 = Travers | first9 = AH. | title = Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal = Circulation | volume = 122 | issue = 18 Suppl 3 | pages = S787-817 | month = Nov | year = 2010 | doi = 10.1161/CIRCULATIONAHA.110.971028 | PMID = 20956226 }}</ref>
+<div class="mw-collapsible mw-collapsed">
-::* ''Dosage and Administration''
-:::* Slow [[IV|IV injection]] 2–4 mg (over 1–5 minutes) every 5–30 minutes as needed.
+======Dopamine======
-<!--
-::* ''Indications''
+<div class="mw-collapsible-content">
-:::* Relief of severe [[pain]] as in severe [[injuries]] or in severe [[chronic pain]] associated with terminal [[cancer]] after all non-[[narcotic]] [[analgesic]]s have failed.
-:::* Relief of [[chest discomfort]] that is unresponsive to [[nitrate]]s in [[STEMI]] [[ACC AHA guidelines classification scheme|(Class I, LOE C)]] and [[unstable angina]] or [[NSTEMI]] [[ACC AHA guidelines classification scheme|(Class IIa, LOE C)]].
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="DOPAMINE HCL injection, solution">{{Cite web  | last =  | first =  | title = DOPAMINE HCL INJECTION, SOLUTION [AMERICAN REGENT, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=e061fb3e-afd7-4188-b5fb-617ac1d3e38d | publisher =  | date =  | accessdate = }}</ref>
-:::* Management of [[dyspnea]] associated with [[heart failure|acute left ventricular failure]] and [[pulmonary edema]] to relieve [[anxiety]] and reduce [[preload]].
+:* Suggested Dilution: transfer contents of one or more ampuls or vials by aseptic technique to either 250 mL or 500 mL of one of the following sterile intravenous solutions
-:::* Preoperative [[sedation]] to facilitate [[anesthesia]] induction and reduce [[anesthetic]] dosage.
+::* Sodium Chloride Injection
--->
+::* Dextrose (5%) Injection
-::* ''Contraindications''
+::* Dextrose (5%) and Sodium Chloride (0.9%) Injection
-:::* [[Hypersensitivity]] to [[morphine sulfate]] is one of the contraindications to its use.
+::* 5% Dextrose in 0.45% Sodium Chloride Solution
-:::* [[Morphine]] should not be used in [[convulsion|convulsive states]], such as those occurring in [[status epilepticus]], [[tetanus]], and [[strychnine]] poisoning.
+::* Dextrose (5%) in Lactated Ringer’s Solution
-:::* [[Morphine]] is also contraindicated in the following conditions: [[respiratory insufficiency|respiratory insufficiency or depression]]; [[bronchial asthma]]; [[heart failure]] secondary to [[COPD|chronic lung disease]]; [[cardiac arrhythmia]]s; increased [[ICP|intracranial or cerebrospinal pressure]]; [[head injury|head injuries]]; [[brain tumor]]; acute [[alcoholism]]; and [[delirium tremens]].
+::* Sodium Lactate (1/6 Molar) Injection
-<!--
+::* Lactated Ringer’s Injection
-::* ''Precautions''
+:* Suggested Regimen:
-:::* May cause [[Hypoventilation|respiratory depression]]
+::* Begin administration of diluted solution at doses of 2–5 μg/kg/minute in patients who are likely to respond to modest increments of heart force and renal perfusion.
-:::* May exacerbate [[hypotension]] in [[hypovolemia|volume-depleted]] patients.
+::* In more seriously ill patients, begin administration of diluted solution at doses of 5 μg/kg/minute and increase gradually, using 5–10 μg/kg/minute increments, up to 20–50 μg/kg/minute as needed.
--->
+::* If doses of 50 μg/kg/minute are required, it is suggested that urine output be checked frequently. Should the urine flow begin to decrease in the absence of hypotension, reduction of dosage should be considered.
+::* Treatment of all patients requires constant evaluation of therapy in terms of the blood volume, augmentation of myocardial contractility, and distribution of peripheral perfusion. Dosage should be adjusted according to the patient’s response, with particular attention to diminution of established urine flow rate, increasing tachycardia or development of new dysrhythmias as indices for decreasing or temporarily suspending the dosage.
+* Contraindications
+:* Pheochromocytoma
+:* Uncorrected tachyarrhythmias or ventricular fibrillation
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Phenylephrine======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="Hollenberg-2011">{{Cite journal  | last1 = Hollenberg | first1 = SM. | title = Vasoactive drugs in circulatory shock. | journal = Am J Respir Crit Care Med | volume = 183 | issue = 7 | pages = 847-55 | month = Apr | year = 2011 | doi = 10.1164/rccm.201006-0972CI | PMID = 21097695 }}</ref><ref name="PHENYLEPHRINE HYDROCHLORIDE INJECTION">{{Cite web  | last =  | first =  | title = PHENYLEPHRINE HYDROCHLORIDE INJECTION [BAXTER HEALTHCARE CORPORATION] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=72348406-e74f-46c5-b93d-34d07cffe1fd | publisher =  | date =  | accessdate = }}</ref>
+:* Suggested Dilution:
+::* Add 10 mg of the drug (1 mL of 1 percent solution) to 500 mL of Dextrose Injection or Sodium Chloride Injection (providing a 1:50,000 solution).
+:* Suggested Regimen:
+::* To raise the blood pressure rapidly, start the infusion at about 100 μg to 180 μg per minute (based on 20 drops per mL this would be 100 to 180 drops per minute).
+::* When the blood pressure is stabilized (at a low normal level for the individual), a maintenance rate of 40 μg to 60 μg per minute usually suffices (based on 20 drops per mL this would be 40 to 60 drops per minute).
+::* If a prompt initial pressor response is not obtained, additional increments of phenylephrine (10 mg or more) are added to the infusion bottle. The rate of flow is then adjusted until the desired blood pressure level is obtained.
+* Contraindications
+:* Severe hypertension
+:* Ventricular tachycardia
+:* Hypersensitivity to phenylephrine
+</div></div>
+<div class="mw-collapsible mw-collapsed">
+======Vasopressin======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="Hollenberg-2011">{{Cite journal  | last1 = Hollenberg | first1 = SM. | title = Vasoactive drugs in circulatory shock. | journal = Am J Respir Crit Care Med | volume = 183 | issue = 7 | pages = 847-55 | month = Apr | year = 2011 | doi = 10.1164/rccm.201006-0972CI | PMID = 21097695 }}</ref><ref name="VASOPRESSIN INJECTION">{{Cite web  | last =  | first =  | title = PITRESSIN (VASOPRESSIN) INJECTION [JHP PHARMACEUTICALS LLC] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=1b316ff5-b7f8-4509-acc4-fd263d0a1703 | publisher =  | date =  | accessdate = }}</ref>
+:* Suggested Regimen:
+::* Adjunctive use of a low dose of vasopressin (0.01–0.04 U/min) to catecholamine may reduce its dosage requirement in patients with refractory shock.
+* Contraindications
+:* Anaphylaxis or hypersensitivity to the drug or its components
+</div></div>
-<!--
+===Cardiac Output Optimization===
-* [[Nitroprusside]]<ref name="Chatterjee-1973">{{Cite journal  | last1 = Chatterjee | first1 = K. | last2 = Parmley | first2 = WW. | last3 = Ganz | first3 = W. | last4 = Forrester | first4 = J. | last5 = Walinsky | first5 = P. | last6 = Crexells | first6 = C. | last7 = Swan | first7 = HJ. | title = Hemodynamic and metabolic responses to vasodilator therapy in acute myocardial infarction. | journal = Circulation | volume = 48 | issue = 6 | pages = 1183-93 | month = Dec | year = 1973 | doi =  | PMID = 4762476 }}</ref>
+<div class="mw-collapsible mw-collapsed">
-:* Initial dose: 16 μg/min
-:* Adjust the infusion rate to maintain a [[PCWP]] of 15–18 mm Hg without causing a marked decrease in [[arterial pressure]].
--->
+======Dobutamine======
+<div class="mw-collapsible-content">
+* Dosage and Administration<ref name="isbn1616690003">{{cite book | author = | authorlink = | editor = | others = | title = Handbook of Emergency Cardiovascular Care for Healthcare Providers | edition = | language = | publisher = | location = | year = | origyear = | pages = | quote = | isbn = 1616690003 | oclc = | doi = | url = | accessdate = }}</ref><ref name="-2000">{{Cite journal  | title = Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 1: acute coronary syndromes (acute myocardial infarction). The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. | journal = Circulation | volume = 102 | issue = 8 Suppl | pages = I172-203 | month = Aug | year = 2000 | doi =  | PMID = 10966673 }}</ref><ref name="DOBUTAMINE (DOBUTAMINE HYDROCHLORIDE) INJECTION, SOLUTION">{{Cite web  | last =  | first =  | title = DOBUTAMINE (DOBUTAMINE HYDROCHLORIDE) INJECTION, SOLUTION [HOSPIRA, INC.] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=cb842dc2-fb15-48f9-e4b1-ea4280db0199 | publisher =  | date =  | accessdate = }}</ref>
+:* Suggested Dilution: dobutamine injection must be further diluted in an IV container. Dilute 20 mL of dobutamine in at least 50 mL of diluent and dilute 40 mL of dobutamine in at least 100 mL of diluent. Use one of the following intravenous solutions as a diluent:
+::* Dextrose Injection 5%
+::* Dextrose 5% and Sodium Chloride 0.45% Injection
+::* Dextrose 5% and Sodium Chloride 0.9% Injection
+::* Dextrose Injection 10%, Isolyte® M with 5% Dextrose Injection
+::* Lactated Ringer’s Injection
+::* 5% Dextrose in Lactated Ringer’s Injection
+::* Normosol®-M in D5-W
+::* 20% Osmitrol® in Water for Injection
+::* Sodium Chloride Injection 0.9%
+::* Sodium Lactate Injection
+:* Suggested Regimen:
+::* The rate of infusion needed to increase cardiac output usually ranged from 2.5–15 mcg/kg/min.
+::* On rare occasions, infusion rates up to 40 mcg/kg/min have been required to obtain the desired effect.
+* Contraindications
+:* Idiopathic hypertrophic subaortic stenosis
+:* Hypersensitivity to dobutamine
-====Afterload <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]</SMALL></SMALL>====
+</div></div>
-====Cardiac Index <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]</SMALL></SMALL>====
+<div class="mw-collapsible mw-collapsed">
+======Milrinone======
+<div class="mw-collapsible-content">
-====''Criteria for Acute Myocardial Infarction'' <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|&#91;Return to ''FIRE''&#93;]]</SMALL></SMALL>====
+* Dosage and Administration<ref name="Hollenberg-2011">{{Cite journal  | last1 = Hollenberg | first1 = SM. | title = Vasoactive drugs in circulatory shock. | journal = Am J Respir Crit Care Med | volume = 183 | issue = 7 | pages = 847-55 | month = Apr | year = 2011 | doi = 10.1164/rccm.201006-0972CI | PMID = 21097695 }}</ref><ref name="MILRINONE LACTATE INJECTION">{{Cite web  | last =  | first =  | title = MILRINONE LACTATE (MILRINONE LACTATE) INJECTION, SOLUTION [BAXTER HEALTHCARE CORPORATION] | url = http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=13705c4d-f47e-4158-88d9-4494324142d4 | publisher =  | date =  | accessdate = }}</ref>
+:* Suggested Regimen:
+::* Milrinone should be administered with a loading dose followed by a continuous infusion (maintenance dose).
+::* Loading dose: 50 μg/kg (slowly over 10 minutes)
+::* Maintenance dose: 0.50 μg/kg/min (0.375–0.75 μg/kg/min)
+* Contraindications
+:* Hypersensitivity to milrinone
-* Detection of a rise and/or fall of [[cardiac biomarker]] values (preferably [[cardiac troponin]]) with at least one value above the 99th percentile upper reference limit and '''with''' at least one of the following:<ref name="Thygesen-2012">{{Cite journal  | last1 = Thygesen | first1 = K. | last2 = Alpert | first2 = JS. | last3 = Jaffe | first3 = AS. | last4 = Simoons | first4 = ML. | last5 = Chaitman | first5 = BR. | last6 = White | first6 = HD. | last7 = Thygesen | first7 = K. | last8 = Alpert | first8 = JS. | last9 = White | first9 = HD. | title = Third universal definition of myocardial infarction. | journal = J Am Coll Cardiol | volume = 60 | issue = 16 | pages = 1581-98 | month = Oct | year = 2012 | doi = 10.1016/j.jacc.2012.08.001 | PMID = 22958960 }}</ref>
+</div></div>
-:* Symptoms of [[ischemia]]
+==Do's==
-:* New or presumably new significant [[ST-segment]]–[[T wave]] (ST–T) changes or new [[LBBB|left bundle branch block (LBBB)]].
-:* Development of [[Pathologic Q Waves|pathological Q waves]] in the [[ECG]].
-:* Imaging evidence of new loss of viable [[myocardium]] or new region wall motion abnormality.
-:* Identification of an intracoronary [[thrombus]] by [[angiography]] or [[autopsy]].
-<!--
-❑&nbsp;&nbsp;± [[Norepinephrine|<span style="color: #FFFFFF;">Norepinephrine</span>]]
-:❑&nbsp;&nbsp;Initial dose: 0.5–1.0 μg/min [[IV|<span style="color: #FFFFFF;">IV infusion</span>]]
+==Don'ts==
-:❑&nbsp;&nbsp;Titrate to maintain [[SBP|<span style="color: #FFFFFF;">SBP</span>]] at ≥90 mm Hg (up to 40 μg/min)
--->
@@ Line 338: / Line 1,001: @@
 {{reflist|2}}
+[[Category:Resident survival guide]]
+</div><div class="mw-collapsible mw-collapsed"><div class="mw-collapsible-content"></div></div>

Sandbox/00008: Difference between revisions

Latest revision as of 00:09, 6 May 2014

Overview

Causes

Life Threatening Causes

Common Causes

FIRE: Focused Initial Rapid Evaluation

Emergency Revascularization [Return to FIRE]

Complete Diagnostic Approach [Return to FIRE]

Diagnostic Criteria [Return to FIRE]

Criteria for Cardiogenic Shock

Criteria for Acute Myocardial Infarction

Maintenance of Blood Pressure [Return to FIRE]

Norepinephrine

Dopamine

Dobutamine

Nitroglycerin

Nitroprusside

Optimization of Hemodynamic Status [Return to FIRE]

Preload Optimization

Fluid Challenge Protocol

Pulmonary Congestion

Furosemide

Morphine

Afterload Optimization

Nitroglycerin

Nitroprusside

Norepinephrine

Dopamine

Phenylephrine

Vasopressin

Cardiac Output Optimization

Dobutamine

Milrinone

Do's

Don'ts

References

Navigation menu

Emergency Revascularization **[Return to FIRE]**

Complete Diagnostic Approach **[Return to FIRE]**

Diagnostic Criteria **[Return to FIRE]**

Maintenance of Blood Pressure **[Return to FIRE]**

Optimization of Hemodynamic Status **[Return to FIRE]**