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cardio.cardiogenic-shock.rv-predominant.v1

Cardiogenic shock — RV-predominant

cardiologyacuteadultacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to RV-predominant CS (RV-MI, massive PE, pulm HTN crisis, post-CT-surgery RV failure). Specializes hemodynamic phenotype (high CVP + low PCWP + low PA), preload-dependent fluid strategy, pulmonary vasodilation (iNO + inhaled epoprostenol), and RV-MCS device selection (Impella RP or VA-ECMO; AVOID isolated Impella CP). Manifest pointer reuses cardio.cardiogenic-shock.core.v1 manifest. Design-brief pointer reuses parent (RV-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (3)

  • imaging
    RV-MI: ST↑ V4R + proximal RCA culprit on angio + clear lungs
    rv_mi_proximal_rca_on_angio
  • imaging
    Massive PE: hemodynamic compromise + RV strain on POCUS/CT
    massive_pe_with_rv_strain
  • imaging
    Hemodynamic profile: elevated CVP + low PCWP + low PA pressure → RV-predominant
    rv_dilation_low_pcwp_on_swan

Required inputs (6)

  • sbprequired
    vital • used at CONTEXT
    Hypotension despite fluid responsiveness defines RV-CS
  • cvprequired
    vital • used at INITIAL_WORKUP
    Elevated CVP with low PCWP is the RV-predominant hemodynamic signature
  • echo_bedsiderequired
    imaging • used at INITIAL_WORKUP
    RV dilation, RV/LV ratio >1, septal flattening (D-shape), McConnell sign for PE — defines RV failure
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    V4R for RV-MI; S1Q3T3 + RBBB for PE; ST↓ inferior + V1-V2 for posterior MI extension
  • cor_angio_or_ctparequired
    imaging • used at TREATMENT
    Angio for RV-MI culprit; CTPA for massive PE
  • lactaterequired
    lab • used at MONITORING
    Lactate trend for RV-CS perfusion adequacy

12-phase flow (10)

  1. 1FRAME
    RV-predominant CS = low CO + elevated CVP + low/normal PCWP + low PA → preload-dependent + pulmonary-vasodilator-responsive
    inputs: ecg
    advance: RV-predominant phenotype confirmed
  2. 2ENTRY
    Identify etiology: RV-MI (proximal RCA), massive PE, pulm HTN crisis, post-CT-surgery RV failure
    inputs: echo_bedside
    advance: etiology hypothesis documented
  3. 3CONTEXT
    Recent surgery, anticoagulation status, prior pulmonary HTN, RV-MI risk factors
    inputs: sbp
    advance: context complete
  4. 4RED_FLAGS
    Massive PE → consider thrombolysis or thrombectomy; RV-MI with conduction block → temporary pacing
    advance: reversible RV failure causes addressed
  5. 5INITIAL_WORKUP
    PA catheter for CVP/PCWP/PA — RV-predominant signature: high CVP + low PCWP + low PA; echo for RV/LV ratio + septal D-sign
    inputs: cvp, echo_bedside
    actions: cardiogenic_shock
    advance: RV-predominant hemodynamic phenotype confirmed
  6. 6BRANCHING_WORKUP
    RV-MI → cath + reperfusion; PE → thrombolysis vs thrombectomy; pulm HTN crisis → iNO + selective vasodilator
    inputs: cor_angio_or_ctpa
    actions: acs_pathway
    advance: etiology-specific intervention triggered
  7. 7TREATMENT
    Preload optimization (fluid bolus 250-500 mL crystalloid); inhaled NO 20-40 ppm OR inhaled epoprostenol; AVOID isolated Impella CP; consider Impella RP if RV-MCS needed; VA-ECMO if biventricular failure
    inputs: cvp
    actions: cardiogenic_shock, panel.cardiac, panel.renal
    advance: RV-tailored regimen running
  8. 8DISPOSITION
    CICU with PA catheter; pulmonary HTN team if pulm HTN crisis; CT surgery if post-op RV failure
    advance: CICU + appropriate team confirmed
  9. 9MONITORING
    Continuous CVP + PA pressure + CO; q1h lactate × 6h; RV/LV ratio on echo daily
    inputs: lactate
    actions: panel.cardiac
    advance: monitoring cadence established
  10. 10FOLLOWUP
    If RV-MI: standard post-MI care + GDMT if EF reduced; if PE: long-term AC + post-PE syndrome screen; if pulm HTN: PH center referral
    advance: etiology-specific follow-up plan booked