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</div>}} | </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;| A08 | | | | | | | | |A08=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: preload'''</BIG> | {{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|<span style="color: #FFFFFF;">(click for details)</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="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: preload'''</BIG> | |||
❑ '''Goal: [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 14–18 mm Hg''' | ❑ '''Goal: [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 14–18 mm Hg''' | ||
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{{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;| | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A10 | | | | | | | | |A10=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: afterload'''</BIG> | ||
❑ '''Goal: [[MAP|<span style="color: #FFFFFF;">MAP</span>]] >60 mm Hg, [[SVR|<span style="color: #FFFFFF;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>''' | ❑ '''Goal: [[MAP|<span style="color: #FFFFFF;">MAP</span>]] >60 mm Hg, [[SVR|<span style="color: #FFFFFF;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>''' | ||
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</div>}} | </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;| | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A11 | | | | | | | | |A11=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: cardiac index'''</BIG> | ||
❑ '''Goal: [[CI|<span style="color: #FFFFFF;">CI</span>]] >2.2 L/min/m<sup>2</sup>''' | ❑ '''Goal: [[CI|<span style="color: #FFFFFF;">CI</span>]] >2.2 L/min/m<sup>2</sup>''' | ||
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: ❑ ± [[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>}} | : ❑ ± [[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>}} | ||
{{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;| | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A12 | | | | | | | | |A12=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate goals'''</BIG> | ||
❑ [[SaO2|<span style="color: #FFFFFF;">SaO2</span>]] >90%–92% | ❑ [[SaO2|<span style="color: #FFFFFF;">SaO2</span>]] >90%–92% | ||
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❑ ± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">electrolyte disturbance</span>]]</div>}} | ❑ ± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">electrolyte disturbance</span>]]</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;| | {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A13 |-| A14 | | | | | |A13=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''[[{{PAGENAME}}#Criteria for Acute Myocardial Infarction|<span style="color: #FFFFFF;">ACS likely? ''(click for details)''</span>]]'''</BIG> | ||
❑ [[cardiac biomarkers|<span style="color: #FFFFFF;">Positive cardiac biomarkers (cTnT, cTnI, or CK-MB)</span>]] | ❑ [[cardiac biomarkers|<span style="color: #FFFFFF;">Positive cardiac biomarkers (cTnT, cTnI, or CK-MB)</span>]] | ||
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</div> | </div> | ||
| | |A14=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 20px;"><BIG>'''YES, then manage as <br> UA/STEMI <br> and proceed to <br> [[{{PAGENAME}}#Acute Ischemia Pathway|<span style="color: #FFFFFF;">acute ischemia pathway</span>]]'''</BIG></div>}} | ||
</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;| 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>}} | {{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>}} | ||
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==Do's== | ==Do's== | ||
===='' | ====''Immediate management'' <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|Return to ''FIRE'']]</SMALL></SMALL>==== | ||
: | |||
< | |||
* Ventilatory support is crucial for maintenance of adequate oxygenation and usually requires [[intubation]] with [[mechanical ventilation]]. | * Ventilatory support is crucial for maintenance of adequate oxygenation and usually requires [[intubation]] with [[mechanical ventilation]]. | ||
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::* May exacerbate [[hypotension]] in [[hypovolemia|volume-depleted]] patients. | ::* May exacerbate [[hypotension]] in [[hypovolemia|volume-depleted]] patients. | ||
====''Criteria for Acute Myocardial Infarction''==== | ====''Criteria for Cardiogenic Shock'' <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|Return to ''FIRE'']]</SMALL></SMALL>==== | ||
* ''Criteria for bedside diagnosis''<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]] <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]]) | |||
:* Presence of [[myocardial]] dysfunction after exclusion or correction of non-[[myocardial]] factors contributing to [[hypoperfusion|tissue hypoperfusion]] (such as [[hypovolemia]], [[hypoxia]], and [[acidosis]]) | |||
* ''Criteria based on hemodynamic parameters''<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]] <90 mm Hg or [[mean arterial pressure|MAP]] 30 mm Hg below baseline in preexisting [[hypertension]] for at least 30 minutes) | |||
:* Depressed [[cardiac index]] (<1.8 L/min/m<sup>2</sup> of [[body surface area|BSA]] without support or <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]] (>15 mm Hg). | |||
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:* Adequate filling pressure (left ventricular end-diastolic pressure >18 mm Hg or right ventricular end-diastolic pressure >10–15 mm Hg) | |||
:* Elevated [[arteriovenous oxygen difference]] (>5.5 mL/dL) | |||
--> | |||
====''Criteria for Acute Myocardial Infarction'' <SMALL><SMALL>[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|Return to ''FIRE'']]</SMALL></SMALL>==== | |||
* 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> | * 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> |
Revision as of 13:18, 21 April 2014
Cardiogenic Shock Resident Survival Guide |
---|
Overview |
Causes |
FIRE |
Diagnosis |
Treatment |
Do's |
Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Zaghw, MBChB. [2]
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
- Acute mitral regurgitation (papillary muscle rupture, chordae tendinae rupture)
- Free wall rupture
- Hypertrophic cardiomyopathy
- Obstruction to left ventricular filling (mitral stenosis, left atrial myxoma)
- Obstruction to left ventricular outflow tract (aortic stenosis, hypertrophic obstructive cardiomyopathy)
- Ventricular septal defect
- 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 the salmon color 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; MVO2, mixed venous oxygen saturation; 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; SMA-7, sequential multiple analysis-7.
Does the patient have cardinal findings that increase the pretest probability of cardiogenic shock?
❑ Evidence of hypoperfusion
| |||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||
Cardiogenic shock suspected | |||||||||||||||||||||||
Immediate management (click for details)
❑ Intubation with mechanical ventilation ❑ ± Norepinephrine IV infusion 0.1–2.0 μg/kg/min | |||||||||||||||||||||||
Immediate Workup
❑ Lactate ❑ Hold antihypertensive medications | |||||||||||||||||||||||
Cardiogenic shock confirmed (click for details) | |||||||||||||||||||||||
Hemodynamic optimization: preload
❑ Goal: PCWP 14–18 mm Hg
| |||||||||||||||||||||||
Hemodynamic optimization: afterload
❑ Goal: MAP >60 mm Hg, SVR 800–1200 dyn·s·cm−5
| |||||||||||||||||||||||
Immediate goals
❑ SaO2 >90%–92% ❑ CVP 8–12 mm Hg ❑ MVO2 >60% ❑ ScvO2 >70% ❑ Hemoglobin >7–9 g/dL ❑ Lactate <2.2 mM/L ❑ Urine output >0.5 mL/kg/h ❑ ± Correct arrhythmia ❑ ± Correct electrolyte disturbance | |||||||||||||||||||||||
ACS likely? (click for details)
❑ Positive cardiac biomarkers (cTnT, cTnI, or CK-MB) ❑ Symptoms of myocaridal ischemia ❑ New significant ECG findings of myocardial ischemia | |||||||||||||||||||||||
No, then proceed to complete diagnostic approach | |||||||||||||||||||||||
Acute Ischemia Pathway
Complete Diagnostic Approach
Treatment
Do's
Immediate management Return to FIRE
- Ventilatory support is crucial for maintenance of adequate oxygenation and usually requires intubation with mechanical ventilation.
- IV bolus normal saline should be waived in the presence of pulmonary edema.
- Dosage and Administration
- Mix 1 ampule (4 mg) of norepinephrine in 250 mL of D5W or D5NS. Avoid dilution in normal saline alone.
- IV infusion 0.5–1.0 μg/min; titrated to raise blood pressure (up to 30–40 μg/min).
- Indications
- Blood pressure control in certain acute hypotensive states (e.g., pheochromocytomectomy, sympathectomy, poliomyelitis, spinal anesthesia, myocardial infarction, septicemia, blood transfusion, and drug reactions).
- Adjunct in the treatment of cardiac arrest and profound hypotension.
- Precautions
- Dosage and Administration
- Slow IV injection 2–4 mg (over 1–5 minutes) every 5–30 minutes as needed.
- Indications
- Relief of severe pain as in severe injuries or in severe chronic pain associated with terminal cancer after all non-narcotic analgesics have failed.
- Relief of chest discomfort that is unresponsive to nitrates in STEMI (Class I, LOE C) and unstable angina or NSTEMI (Class IIa, LOE C).
- Management of dyspnea associated with acute left ventricular failure and pulmonary edema to relieve anxiety and reduce preload.
- Preoperative sedation to facilitate anesthesia induction and reduce anesthetic dosage.
- Precautions
- May cause respiratory depression
- May exacerbate hypotension in volume-depleted patients.
Criteria for Cardiogenic Shock Return to FIRE
- 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)
- 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 Return to FIRE
- 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:[12]
- Symptoms of ischemia
- New or presumably new significant ST-segment–T wave (ST–T) 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 region wall motion abnormality.
- Identification of an intracoronary thrombus by angiography or autopsy.
Don'ts
- Do not test orthostatic hypotension in hypotensive patients.
- Do not rely solely on SpO2 readings from pulse oximeter. SaO2 from blood gas analysis provides more precise status of oxygenation.
- Do not administer low-dose dopamine (<5 μg/kg/min) to preserve renal function in patients with shock.
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.
- ↑ "NOREPINEPHRINE BITARTRATE INJECTION".
- ↑ 4.0 4.1 Handbook of Emergency Cardiovascular Care for Healthcare Providers. ISBN 1616690003.
- ↑ "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) - ↑ Hollenberg, SM.; Kavinsky, CJ.; Parrillo, JE. (1999). "Cardiogenic shock". Ann Intern Med. 131 (1): 47–59. PMID 10391815. Unknown parameter
|month=
ignored (help) - ↑ 8.0 8.1 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, 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, 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, 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)