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cardio.cardiogenic-shock.scai-e.v1

Cardiogenic shock — SCAI Stage E (extremis / refractory)

cardiologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to SCAI Stage E (extremis / refractory). Inherits CS arc from parent; specializes for VA-ECMO primary modality, ECPR per ARREST trial criteria, SAVE score outcome prediction, and 24-72h ethics-mandated futility discussion. Manifest pointer reuses cardio.cardiogenic-shock.core.v1 manifest. Design-brief pointer reuses parent (E-stage specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (3)

  • symptom
    Cardiac arrest with ongoing CPR — consider ECPR per ARREST trial criteria
    cardiac_arrest_with_ongoing_cpr
  • vital_abnormality
    MAP <60 + lactate ≥6 + multi-organ failure on MCS + max pharmacology — E-stage extremis
    refractory_shock_on_max_mcs
  • history
    CS-related arrest with ROSC but persistent extremis — E-stage post-arrest
    cs_related_arrest_post_rosc

Required inputs (5)

  • sbprequired
    vital • used at CONTEXT
    E-stage typically MAP <60 despite all interventions; defines extremis
  • maprequired
    vital • used at RED_FLAGS
    MAP target ≥65 unattainable on max MCS + pharmacology = E-stage
  • lactaterequired
    lab • used at MONITORING
    Lactate ≥6-10 mmol/L typical of E-stage; SAVE score input
  • arterial_phrequired
    lab • used at INITIAL_WORKUP
    pH <7.2 typical of E-stage extremis; SAVE score input + futility marker
  • echo_bedsiderequired
    imaging • used at INITIAL_WORKUP
    Confirm cardiac etiology + identify reversible causes (tamponade, mechanical) before ECPR

12-phase flow (10)

  1. 1FRAME
    SCAI E = cardiac arrest with ongoing CPR/ECMO, OR refractory shock requiring multiple interventions, OR CS-related arrest
    inputs: sbp
    advance: E-stage criteria met
  2. 2ENTRY
    Activate ECMO team if criteria met; ARREST-style ECPR if witnessed VF/VT arrest with bystander CPR <10 min
    inputs: map
    advance: ECMO team paged or ECPR decision made
  3. 3CONTEXT
    Pre-arrest functional status, witnessed status, bystander CPR duration, no-flow time — drives ECPR candidacy
    advance: ECPR candidacy assessed
  4. 4RED_FLAGS
    Reversible causes: tamponade (echo), tension PTX (POCUS), massive PE (POCUS RV), hyperkalemia (POC labs)
    inputs: echo_bedside
    advance: reversible causes addressed
  5. 5INITIAL_WORKUP
    ABG + lactate + POC chemistry; SAVE score for VA-ECMO outcome prediction; coronary angio if AMI suspected
    inputs: lactate, arterial_ph
    actions: acs_pathway
    advance: SAVE risk class documented
  6. 6BRANCHING_WORKUP
    VA-ECMO cannulation (femoral-femoral standard); LV venting if Impella adjunct (LV distention prevention)
    advance: VA-ECMO deployed
  7. 7TREATMENT
    VA-ECMO primary; Impella adjunct for LV venting; consider IABP for afterload reduction; max pharmacology continued
    inputs: map
    actions: cardiogenic_shock, panel.cardiac, panel.renal
    advance: VA-ECMO running + adjunct devices placed
  8. 8DISPOSITION
    CICU with ECMO team; advanced HF center if not on-site (transport on ECMO)
    advance: CICU + ECMO team confirmed
  9. 9MONITORING
    Continuous PA catheter, daily echo (LV venting + recovery), q1h ABG/lactate, daily SAVE score reassessment, daily SOFA
    inputs: lactate
    actions: panel.cardiac
    advance: monitoring cadence established
  10. 10FOLLOWUP
    Futility discussion at 24-72h; ethics consult if no recovery; bridge to durable LVAD or transplant if eligible; palliative if not
    advance: futility/recovery decision made