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cardio.cardiogenic-shock.scai-d.v1

Cardiogenic shock — SCAI Stage D (deteriorating)

cardiologyacuteadultacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to SCAI Stage D (deteriorating). Inherits etiology + initial resuscitation + shock-team flow from parent; specializes for MCS escalation (Impella CP per DanGer Shock 2024), second-pressor strategy (vasopressin V1 adjunct), and advanced HF center transfer. Manifest pointer reuses cardio.cardiogenic-shock.core.v1 manifest. Design-brief pointer reuses parent (D-stage specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (3)

  • vital_abnormality
    SBP <90 / MAP <65 despite norepinephrine + dobutamine — SCAI D
    persistent_hypotension_on_pressors
  • lab_abnormality
    Lactate rising or static ≥2 mmol/L despite ≥6h initial therapy — failure to clear
    rising_lactate_on_therapy
  • symptom
    New AKI + transaminitis + altered mentation on first-line therapy — D-stage progression
    multi_organ_involvement

Required inputs (6)

  • sbprequired
    vital • used at CONTEXT
    Persistent SBP <90 despite ≥2 hemodynamic agents defines deterioration
  • maprequired
    vital • used at RED_FLAGS
    MAP <65 despite NE + inotrope drives MCS escalation per DanGer Shock
  • lactaterequired
    lab • used at MONITORING
    Trend (not single value) defines deterioration vs response; lactate rise on therapy is a hard MCS trigger
  • creatininerequired
    lab • used at CONTEXT
    New AKI = D-stage organ marker; also drives MCS/contrast safety planning
  • echo_bedsiderequired
    imaging • used at INITIAL_WORKUP
    LVEF + RV strain + valvular + tamponade exclusion before MCS device selection
  • cor_angiorequired
    imaging • used at TREATMENT
    Confirms reperfusion completeness; identifies salvageable myocardium pre-MCS

12-phase flow (10)

  1. 1FRAME
    SCAI D = classic CS not responding to initial therapy → escalating support, MCS active or imminent, deteriorating
    inputs: sbp, lactate
    advance: D-stage criteria met
  2. 2ENTRY
    Activate shock team; consider transfer to advanced HF/MCS center if not on-site
    inputs: map
    advance: shock team paged
  3. 3CONTEXT
    Etiology (AMI vs HF vs valvular vs myocarditis) — drives device + reperfusion strategy
    inputs: creatinine
    advance: etiology hypothesis documented
  4. 4RED_FLAGS
    Mechanical complication rule-out (papillary, VSR, free-wall) before committing to MCS strategy
    inputs: echo_bedside
    advance: mechanical complications excluded or surgical plan made
  5. 5INITIAL_WORKUP
    Echo + PA catheter (Swan-Ganz) for hemodynamic profiling — CI, PCWP, PVR, RV stroke work
    inputs: echo_bedside
    actions: cardiogenic_shock
    advance: hemodynamic phenotype documented
  6. 6BRANCHING_WORKUP
    MCS device selection: Impella CP (LV-predominant) vs IABP (bridge) vs VA-ECMO (biventricular failure)
    inputs: cor_angio
    advance: MCS device decision made
  7. 7TREATMENT
    Impella CP per DanGer Shock 2024; second pressor (vasopressin 0.03 U/min); inotrope continuation; VA-ECMO if MCS inadequate
    inputs: map
    actions: cardiogenic_shock, panel.cardiac, panel.renal
    advance: MCS deployed + 2nd pressor titrated
  8. 8DISPOSITION
    CICU with MCS team; advanced HF center transfer if local MCS expertise limited
    advance: CICU bed + MCS team confirmed
  9. 9MONITORING
    Continuous PA catheter; q1h lactate × 6h then q4h; daily echo; SOFA score q12h
    inputs: lactate
    actions: panel.cardiac
    advance: monitoring cadence established
  10. 10FOLLOWUP
    If recovery: MCS wean, GDMT initiation, advanced HF clinic; if no recovery → SCAI E pathway
    advance: recovery vs E-stage decision made