I was hoping to get clarification on the appropriate fluid bolus amounts for a patient suspected to be in cardiogenic shock but not having an identified STEMI. The patient I attended to in this call was found to be in rapid atrial fibrillation and hypotensive, along with appearing pale and having complaints of dizziness. From the 12-lead ECG we did not identify any STEMI. The patient did complain of nausea/vomiting earlier in the day, and also did have a fall approx 1 week earlier where pt fell on his left side. There were multiple factors at play here which may have contributed to this patient's complaints of dizziness and hypotension. In hindsight, I am now suspicious that this patient was in cardiogenic shock. In the cardiogenic shock auxiliary directive, it states that the patient needs to have a STEMI positive 12-lead ECG and be in cardiogenic shock to be administered a halved saline fluid bolus (10mL/kg). However, in the IV fluid auxiliary directive, it only requires the patient to be in cardiogenic shock to have the halved saline fluid bolus administered. In hindsight, I believe I should have administered approx 500ml of saline instead of the 1000ml I did administer. 

The Cardiogenic Shock Medical Directive is designed to deliver less IV Fluids due to the potential for overload on a heart we know is weakened due the myocardial injury objectively seen via STEMI on 12-Lead ECG. You are correct that there are other conditions that can place stress on the heart (such as prolonged arrythmia, as was potentially the case here) and therefore decrease the ability of the heart to distribute increased preload, via IV fluids. These other conditions are harder to define than a STEMI, for the purposes of a Medical Directive. There is built-in safety in the IV Fluid and Therapy Medical Directive, wherein reassessments for signs of fluid overload must be completed every 250mL. However, should you every have a clinical question on treatment decisions, a patch to the BHP can be completed. 

Cardiac/Circulation,Cardiogenic Shock,Intravenous and Fluid Therapy

Arrythmia, Cardiogenic shock, IV fluid bolus, Preload, STEMI

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