Adult Medical Emergency Handbook - Scottish Intensive Care Society

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Do not hesitate to seek a Cardiology opinion if there is no
improvement and refer to ICU early.
• In severe or resistant cases support with intra-aortic balloon pump
may be life saving.
• Consider insertion of an arterial line and pulmonary artery catheter
to measure cardiac output, guide the administration of inotropes,
and assess response. Particularly useful in hypotension.
• Vasoactive drugs may be required and should be administered
under expert guidance.
• Digitalisation, for its inotropic effect, may be beneficial but 3-6
hours may elapse before there is any appreciable effect. Loading
doses as per AF (caution in renal impairment).
RIGHT VENTRICULAR INFARCTION/FAILURE
Diagnosis
• Right Ventricular Failure (hypotension and elevated JVP/hepatic
congestion) in the absence of clinical /radiological evidence of
pulmonary congestion suggests the possibility of right ventricular
infarction. This is more likely in association with acute inferior/
infero-posterior infarctions.
• The right ventricular leads on the 12 lead ECG (V3R & V4R placed
in the equivalent positions but to the right of the sternum as V3 &
V4) may show ST elevation, confirming RV infarction.
• Echocardiogram and/or the insertion of a pulmonary artery
catheter will confirm the diagnosis.
Management
• Diuretics or vasodilators/GTN should be avoided as right
ventricular function is dependent upon high filling pressures.
• If hypotension/oliguria persist, administer IV fluids and consider
haemodynamic monitoring using a PA catheter.
• In the event of persistent hypotension/low cardiac output inotropic
therapy may be required. Seek expert advice.
CARDIOGENIC SHOCK
Combined Cardiology and ICU referral early is appropriate.
Diagnosis
Cardiogenic shock should be considered if the following features are
present:
112 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11