Expansion
Sit up, oxygen, nitrates, diuretics, and treat the cause
Expansion
POND, with the patient sat upright:
- P - Position: sit upright with the legs dependent, which reduces venous return
- O - Oxygen, to target saturations, with CPAP if hypoxic despite it
- N - Nitrate infusion, if the systolic pressure is above about 90 mmHg. The most effective preload reducer
- D - Diuretic: intravenous furosemide
Then treat the precipitant, using the mnemonic “FAILURE”: Forgot medication, Arrhythmia (especially atrial fibrillation), Ischaemia or Infarction, Lifestyle and fluid or salt excess, Upregulation (pregnancy, thyrotoxicosis), Renal failure, Embolism.
Points that are commonly got wrong
- Furosemide works in the first hour mainly by venodilatation, not diuresis, which begins later
- Opioids are no longer recommended routinely, having been associated with worse outcomes
- Beta blockers are continued unless the patient is in cardiogenic shock or markedly bradycardic, and are not started acutely
- CPAP improves oxygenation and reduces intubation, by raising intrathoracic pressure and reducing both preload and afterload
Cardiogenic shock, with hypotension and hypoperfusion, requires inotropes and urgent specialist input rather than further vasodilatation.