Patient handout

Cardiogenic shock — Post pacemaker / ICD / CRT implantation

PRODUCTION

1. Your condition

This handout is for cardiogenic shock — post pacemaker / icd / crt implantation. Your care team identified this based on: hours-to-days post-ppm/icd/crt implant: sbp <90 + tachycardia + signs of low co.

Other reasons your team may use this plan: stat echo: new pericardial effusion with chamber compression — cardiac perforation tamponade; post-procedure cxr: ipsilateral pneumothorax (especially after subclavian access); post-procedure cxr: lead tip outside cardiac silhouette → perforation; lead in unexpected location → dislodgement.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
norepinephrine	0.05-0.5 mcg/kg/min IV titrate to MAP ≥65	IV	continuous	SOAP-II PMID 20200382 — first-line vasopressor; lower arrhythmia than dopamine
isoproterenol	2-10 mcg/min IV titrate to HR 60-80	IV	continuous	Beta1/2 agonist increases sinus rate and AV conduction; bridge while transcutaneous pacing in place and EP lab readied for lead repositioning
atropine	0.5-1 mg IV q3-5 min, max 3 mg	IV	PRN	Blocks vagal tone; effective for vagally-mediated bradycardia during sheath manipulation; ineffective for high-grade AV block from lead dislodgement
idarucizumab	5 g IV (two 2.5 g vials)	IV	once	Specific dabigatran reversal; rapid onset; reduces bleeding-related morbidity
andexanet alfa	Low dose (400 mg bolus + 4 mg/min × 120 min) or High dose (800 mg + 8 mg/min × 120 min) per ANNEXA-4 dosing	IV	bolus + infusion	Specific Factor Xa inhibitor reversal; expensive; reserve for life-threatening bleeding
four-factor PCC	25-50 IU/kg IV	IV	once	Rapid VKA reversal; faster than FFP; preferred per ACC 2017 expert consensus on AC reversal
vasopressin	0.03-0.04 U/min fixed	IV	continuous	V1 vasoconstriction add-on if NE >0.3 mcg/kg/min and persistent shock

Plan: Post-PPM/ICD/CRT CS — etiology-tailored regimen (perforation tamponade / pneumothorax / lead dislodgement / air embolism / hematoma / vagal)

3. When to call your provider

Contact your care team if any of the following happen:

Device alarm or low battery → EP urgent
Late lead complication → EP service

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Post-PPM/ICD/CRT patient with new pericardial effusion + chamber compression on STAT echo + JVD + hypotension → emergent pericardiocentesis(life-threatening)
Post-PPM/ICD/CRT patient (especially after subclavian access) with hypoxemia + hypotension + tracheal deviation + ipsilateral hyperresonance + absent breath sounds → tension PTX with PEA(life-threatening)
Pacemaker-dependent patient (CHB, AV-junction-ablated) with abrupt syncope, asystolic arrest, or symptomatic bradycardia → loss of capture from lead dislodgement(life-threatening)
Post-CIED patient with sudden focal neuro deficit, altered mental status, or seizure during/after venous access → cerebral air embolism(life-threatening)
Post-CIED patient on uninterrupted DOAC/warfarin with large expanding pocket hematoma + hemodynamic compromise from extension or tamponade physiology
Post-CIED patient with delayed presentation 1-4 weeks post-implant with chest pain + dyspnea + new pericardial effusion → late lead perforation

5. Follow-up

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)

6. Sources

Guideline: HRS 2024 CIED Complications Statement + 2018 ACC/AHA/HRS Bradycardia and Cardiac Conduction Delay Guideline + SCAI 2022 CS staging (Naidu PMID 35718438)