You review a patient in the CCU who was admitted earlier with a large anterior myocardial infarction treated with primary angioplasty. He has no bystander disease but the presentation was late. The echocardiogram shows severe LV impairment. There is pulmonary oedema which you have been treating with furosemide boluses and continuous positive airway pressure non-invasive ventilation. Blood pressure is now 85/50 mmHg and urine output in the last hour is 10 mL. Oxygen saturations are maintained at 94% with high-flow oxygen. He remains alert.
What treatment should you consider next?A) Call an anaesthetist to consider ventilation
This patient has moderate heart failure with pulmonary oedema and significant hypotension. The suggestion is that he may be developing cardiogenic shock. There is evidence of poor organ perfusion, reflected by the urine output, but his ventilation remains reasonable. Inotropic support is the next step. In a patient with BP < 90 mmHg dopamine (inotropic/vasopressor) should be considered. In patients with ‘adequate’ blood pressure (>90 mmHg) dobutamine (inotropic) or levosimendan (inotropic/vasodilator) may be preferable. Noradrenaline (vasopressor) may be preferable in cardiogenic shock or septicaemia.