cardio.cardiogenic-shock.pe-related.v1

Cardiogenic shock — PE-related (massive PE with RV failure)

cardiologyacuteadultacuteinpatienttransitionoutpatient

Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to PE-related cardiogenic shock (massive PE causing acute RV failure with obstructive + cardiogenic overlap). Centerpiece is SYSTEMIC THROMBOLYSIS (alteplase 100 mg IV over 2h, or 50 mg push if cardiac arrest) per ESC 2019 Class I; catheter-directed thrombolysis (EKOS, USAT) if intermediate-high or systemic lysis CI; mechanical thrombectomy (FlowTriever) per FLAME registry; surgical embolectomy if absolute lytic CI; VA-ECMO bridge if persistent shock. Norepinephrine + dobutamine for RV support; iNO 20-40 ppm or inhaled epoprostenol for pulmonary vasodilation; AVOID isolated LV Impella (worsens RV). Long-term apixaban ≥6 mo per AMPLIFY; CTEPH surveillance at 3-6 mo. Manifest pointer reuses cardio.cardiogenic-shock.core.v1 manifest. Design-brief pointer reuses parent (PE-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as Phase E wave 7 variant.

Entry points (4)

imaging
Massive PE on CTPA + RV/LV ratio >1 + septal flattening on bedside echo
massive_pe_on_ctpa_with_rv_strain
symptom
Syncope + acute dyspnea + SBP <90 sustained → suspect massive PE
syncope_dyspnea_with_hypotension
imaging
Bedside echo: McConnell sign (RV free wall hypokinesis with apical sparing) + dilated IVC + septal D-sign
pocus_mcconnell_sign
lab_abnormality
Elevated troponin + BNP in confirmed PE (PESI high risk → cardiogenic shock pathway)
troponin_bnp_elevated_with_pe

Required inputs (9)

sbprequired
vital • used at RED_FLAGS
Sustained SBP <90 for ≥15 min defines massive (high-risk) PE per ESC 2019 (Konstantinides PMID 31504429)
hrrequired
vital • used at CONTEXT
Tachycardia >110 + sustained hypotension drives shock-trigger threshold
echo_bedsiderequired
imaging • used at INITIAL_WORKUP
Bedside echo for McConnell sign, RV/LV ratio >1, septal flattening (D-sign), dilated IVC — defines RV failure and obstructive physiology
ctparequired
imaging • used at INITIAL_WORKUP
CTPA confirms PE + clot burden + saddle vs proximal vs subsegmental; only obtain if hemodynamically tolerable, otherwise treat empirically
troponinrequired
lab • used at INITIAL_WORKUP
RV strain marker + risk stratification (PESI / Bova score); positive troponin upgrades to high-risk PE
bnprequired
lab • used at INITIAL_WORKUP
Elevated BNP/NT-proBNP indicates RV strain in PE (ESC 2019)
lactaterequired
lab • used at RED_FLAGS
Lactate ≥2 marks SCAI Stage C+ shock physiology
creatininerequired
lab • used at CONTEXT
eGFR for contrast (CTPA), DOAC dosing post-discharge
recent_surgery_or_bleedingrequired
history • used at CONTEXT
Bleed-risk + thrombolysis contraindication screen (active bleeding, recent intracranial surgery, recent stroke <3 mo)

12-phase flow (11)

1FRAME
Massive PE causing obstructive + cardiogenic physiology; RV pump failure is the proximate killer; thrombolysis is the upstream fix; route through this engine for hemodynamic management while pulm.pe.core.v1 owns the AC + thrombolysis decision
inputs: sbp, echo_bedside
advance: Massive PE with shock confirmed
2ENTRY
PE response team (PERT) activation; bedside POCUS for McConnell + RV/LV ratio; assess thrombolysis candidacy
inputs: sbp, hr
advance: PERT activated + thrombolysis screen complete
3CONTEXT
Bleed risk, recent surgery/stroke, recent procedures, baseline AC status, code status
inputs: recent_surgery_or_bleeding, creatinine
advance: context complete
4RED_FLAGS
Cardiac arrest pending → empiric reduced-dose alteplase 50 mg IV push; refractory shock → VA-ECMO bridge; absolute thrombolysis CI → surgical embolectomy or catheter-directed thrombectomy
inputs: sbp, lactate
actions: cardiogenic_shock
advance: Tier-1 escalation pathway selected
5INITIAL_WORKUP
CTPA if hemodynamically tolerable (saddle, proximal, clot burden); ECG (S1Q3T3, RBBB, T-wave inversion V1-V4); troponin + BNP + lactate + ABG; bedside echo (RV size, McConnell, septal D, IVC, exclude LV cause)
inputs: ctpa, troponin, bnp, echo_bedside
actions: cardiogenic_shock, panel.cardiac, panel.coag
advance: PE confirmed + RV strain quantified
6BRANCHING_WORKUP
Thrombolysis candidacy review → systemic alteplase first-line if no CI; catheter-directed thrombolysis (EKOS, USAT) if intermediate-high or thrombolysis-relative-CI; surgical embolectomy if thrombolysis absolute CI; mechanical thrombectomy (FlowTriever) per FLAME registry
inputs: recent_surgery_or_bleeding
advance: Reperfusion strategy selected
7RISK_STRATIFICATION
PESI / sPESI for prognosis + ESC 2019 4-tier risk (low / intermediate-low / intermediate-high / high); CardShock + SCAI stage
inputs: lactate
advance: Risk stratified
8TREATMENT
Systemic alteplase 100 mg IV over 2h (or 50 mg push if cardiac arrest) per ESC 2019 Class I; norepinephrine + dobutamine (RV-supporting); inhaled NO 20-40 ppm or inhaled epoprostenol for pulmonary vasodilation; AVOID isolated LV Impella; VA-ECMO bridge if persistent shock; catheter-directed thrombolysis or thrombectomy if systemic CI; surgical embolectomy if absolute CI to lytics
inputs: sbp
actions: cardiogenic_shock
advance: Reperfusion delivered + hemodynamic support running
9DISPOSITION
CICU at PE-response-team-capable center with VA-ECMO availability
advance: Disposition assigned
10MONITORING
Continuous BP + SpO2 + telemetry; lactate q1h × 6h then q4h; serial echo for RV recovery (RV/LV ratio, septal D-sign resolution); coag panel q6h post-lysis × 24h
inputs: lactate
actions: panel.cardiac, panel.coag
advance: Monitoring cadence established
11FOLLOWUP
Long-term anticoagulation per AMPLIFY (apixaban 10 BID × 7d → 5 BID × ≥6 mo); post-PE syndrome screen at 3-6 mo (CTEPH evaluation if persistent dyspnea); thrombophilia workup if unprovoked
advance: Long-term AC + post-PE plan booked