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cardio.cardiogenic-shock.post-pacemaker-implant.v1

Cardiogenic shock — Post pacemaker / ICD / CRT implantation

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to CS occurring within hours-to-days after permanent pacemaker (PPM), implantable cardioverter-defibrillator (ICD), or cardiac resynchronization therapy (CRT) implantation. Etiology differential: cardiac perforation with tamponade (most common dangerous complication, 0.5-1%; higher with active fixation atrial and CRT LV leads; may be acute or delayed up to 4 weeks); pneumothorax with PEA (subclavian access 1-2%; lower with axillary/cephalic); lead dislodgement with abrupt loss of pacing (most common first 24-48h, especially atrial and CRT LV; pacemaker-dependent patients develop asystolic arrest); air embolism (venous access deep inspiration; cerebral via PFO; coronary); pocket hematoma with tamponade physiology (DOAC/warfarin context); vagal-mediated transient hypotension. Workup centerpiece: STAT bedside echo for tamponade (priority), CXR for lead position + PTX, ECG for capture + ischemia, device interrogation. Treatment: emergent pericardiocentesis for tamponade (AVOID PPV — worsens cardiac filling); emergent needle decompression for tension PTX; transcutaneous pacing + isoproterenol bridge for pacemaker-dependent loss of capture; lead repositioning in EP lab; hyperbaric O2 for cerebral air embolism within 6h window; reverse anticoagulation per agent for hematoma with tamponade. Manifest pointer reuses cardio.cardiogenic-shock.core.v1 manifest. Design-brief pointer reuses parent (post-CIED-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 12 variant.

Entry points (6)

  • history
    Hours-to-days post-PPM/ICD/CRT implant: SBP <90 + tachycardia + signs of low CO
    post_ppm_icd_crt_low_co
  • imaging
    STAT echo: new pericardial effusion with chamber compression — cardiac perforation tamponade
    echo_post_implant_pericardial_effusion
  • imaging
    Post-procedure CXR: ipsilateral pneumothorax (especially after subclavian access)
    cxr_post_implant_pneumothorax
  • imaging
    Post-procedure CXR: lead tip outside cardiac silhouette → perforation; lead in unexpected location → dislodgement
    cxr_post_implant_lead_position
  • symptom
    Pacemaker-dependent patient (CHB, AV-junction-ablated) with abrupt syncope/arrest → loss of capture from lead dislodgement
    pacemaker_dependent_loss_of_capture
  • symptom
    Sudden focal neuro deficit or altered mental status during/after venous access → cerebral air embolism
    sudden_neuro_deficit_during_implant

Required inputs (11)

  • sbprequired
    vital • used at RED_FLAGS
    SBP <90 sustained drives shock-trigger threshold; PEA from tension PTX presents with profound hypotension
  • cvprequired
    vital • used at INITIAL_WORKUP
    CVP elevation differentiates tamponade (high CVP + equalization) and tension PTX from vasovagal hypotension
  • echo_post_implantrequired
    imaging • used at INITIAL_WORKUP
    STAT bedside echo: rule out pericardial effusion + chamber compression (lead perforation tamponade); confirm LV/RV function; assess lead position if visible
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    CXR for lead tip position (outside cardiac silhouette = perforation), pneumothorax (ipsilateral apex), hemothorax, and lead dislodgement
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Capture confirmation (paced QRS morphology; loss of capture → lead dislodgement); ischemia/infarct from coronary air embolism
  • lactaterequired
    lab • used at RED_FLAGS
    Lactate trend marks SCAI Stage C+; rising lactate confirms low CO state
  • troponin
    lab • used at INITIAL_WORKUP
    Troponin elevation may indicate myocardial perforation or coronary air embolism
  • creatininerequired
    lab • used at CONTEXT
    eGFR for drug dosing + contrast if re-imaging needed
  • device_interrogationrequired
    history • used at INITIAL_WORKUP
    Lead impedance (high → fracture/dislodgement/perforation; low → insulation breach), R/P-wave amplitude (low → dislodgement), pacing threshold (high → perforation/dislodgement), capture confirmation
  • anticoagulation_statusrequired
    history • used at CONTEXT
    Pre-procedure DOAC/warfarin/heparin status governs hematoma + tamponade risk and reversal decisions
  • pacemaker_dependent_statusrequired
    history • used at CONTEXT
    Pacemaker-dependent patients (CHB, AV-junction-ablated) develop asystolic arrest if loss of capture from lead dislodgement

12-phase flow (11)

  1. 1FRAME
    Post-PPM/ICD/CRT CS = differential of cardiac perforation tamponade (most common dangerous, 0.5-1%), pneumothorax with PEA, lead dislodgement with loss of capture (esp pacemaker-dependent), air embolism (venous access deep inspiration; cerebral via PFO; coronary), vagal-mediated transient hypotension, pocket hematoma with tamponade physiology
    inputs: sbp, lactate
    advance: EP + cardiology + interventional team activated
  2. 2ENTRY
    Identify primary etiology by STAT echo + CXR + ECG + device interrogation: tamponade (pericardiocentesis), pneumothorax (chest tube), lead dislodgement (lead repositioning), air embolism (Trendelenburg + 100% O2 + hyperbaric if cerebral)
    inputs: sbp, cvp
    advance: Etiology hypothesis from echo + CXR + ECG + device interrogation
  3. 3CONTEXT
    Procedure type (PPM single/dual/CRT/ICD), access route (subclavian vs axillary vs cephalic vs femoral), active vs passive lead fixation, pre-procedure anticoagulation status, pacemaker-dependent status, comorbid pulmonary disease (predisposes to PTX)
    inputs: anticoagulation_status, pacemaker_dependent_status, creatinine
    advance: Procedure record reviewed
  4. 4RED_FLAGS
    Acute tamponade (Beck triad — JVD + muffled S1S2 + hypotension) → emergent pericardiocentesis; tension pneumothorax → emergent needle decompression; pacemaker-dependent loss of capture → transcutaneous pacing + isoproterenol bridge; cerebral air embolism with focal deficit → Trendelenburg + 100% O2 + hyperbaric chamber transfer
    inputs: sbp, cvp
    actions: cardiac_tamponade
    advance: Etiology-specific emergent intervention triggered
  5. 5INITIAL_WORKUP
    STAT bedside echo (tamponade rule-out is priority); CXR (lead position + PTX + hemothorax); ECG (capture, ischemia, infarct from coronary air embolism); device interrogation (lead impedance, R/P amplitude, pacing threshold, capture); ABG + lactate; CBC + coag; CT chest if cerebral or coronary air embolism suspected (rule out residual air)
    inputs: echo_post_implant, cxr, ecg, lactate, device_interrogation
    actions: cardiogenic_shock, panel.cardiac, panel.coag
    advance: Etiology classified
  6. 6BRANCHING_WORKUP
    Tamponade → emergent pericardiocentesis (subxiphoid; surgical drainage if recurrent); pneumothorax → chest tube; lead dislodgement → lead repositioning in EP lab; coronary air embolism → re-cath + aspiration if persistent ischemia; cerebral air embolism → hyperbaric O2 chamber transfer
    inputs: echo_post_implant
    advance: Etiology-specific intervention triggered
  7. 7RISK_STRATIFICATION
    SCAI 2022 staging; pacemaker-dependent + loss of capture = high-acuity; tamponade severity (effusion size + chamber compression + hemodynamic compromise)
    inputs: lactate
    advance: Risk stratified
  8. 8TREATMENT
    Standard CS support (NE first-line per SOAP-II; avoid PPV in tamponade — worsens cardiac filling); EMERGENT PERICARDIOCENTESIS for tamponade; chest tube for pneumothorax; transcutaneous pacing + isoproterenol bridge for pacemaker-dependent loss of capture; lead repositioning; reverse anticoagulation if pocket hematoma + tamponade; hyperbaric O2 if cerebral air embolism
    inputs: sbp, lactate
    actions: cardiogenic_shock
    advance: Pressor + procedure-specific intervention active
  9. 9DISPOSITION
    CICU monitoring; EP service for lead repositioning if dislodgement; cardiothoracic surgery if surgical pericardial drainage needed
    advance: Disposition assigned
  10. 10MONITORING
    Continuous telemetry + a-line + repeat echo q4-6h for first 24h post-tamponade; serial CXR for re-expansion of lung; daily device interrogation for lead stability; INR/anti-Xa if anticoagulation reversed
    inputs: lactate
    actions: panel.cardiac
    advance: Monitoring cadence established
  11. 11FOLLOWUP
    Pre-discharge device interrogation + CXR + echo; close EP follow-up at 1-2 weeks; restart anticoagulation per device-procedure-specific protocol; patient education on signs of late perforation (delayed up to 4 weeks)
    advance: EP follow-up + AC plan documented