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cardio.cardiogenic-shock.septic-mixed.v1

Cardiogenic shock — septic-mixed (SICM + distributive overlap)

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to mixed septic + cardiogenic shock overlap (sepsis-induced cardiomyopathy SICM + distributive collapse). Centerpiece is DUAL-BUNDLE LAYERING: SSC 2021 hour-1 (lactate + cultures + abx <60min + cautious 30 mL/kg + NE for MAP <65) AND CS bundle (echo + EARLY low-dose dobutamine when MAP target met but lactate not clearing or ScvO2 <70%). Vasopressin + hydrocortisone for persistent NE >0.25; source control non-negotiable. SICM typically reversible at 7–10d in survivors. Manifest pointer reuses cardio.cardiogenic-shock.core.v1 manifest. Design-brief pointer reuses parent (mixed-shock differences documented inline). AVOID rules: pure vasopressor without inotrope in low-CI; over-resuscitation in SICM; high-dose dobutamine (arrhythmia + ↑ MVO2); milrinone if SBP <90. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as Phase E wave 8 variant.

Entry points (4)

  • lab_abnormality
    Septic shock + persistent low CI / low SvO2 despite NE titration + 30 mL/kg crystalloid → mixed CS overlap
    septic_shock_with_persistent_low_co
  • imaging
    Bedside echo during sepsis: new global LV dysfunction with EF drop ≥10 points from baseline (SICM phenotype, often reversible at 7–10d)
    sicm_global_lv_dysfunction_on_echo
  • lab_abnormality
    STAT troponin elevated in septic patient WITHOUT primary ACS pattern on ECG → type-2 demand-mismatch ischemia or SICM
    troponin_elevated_in_sepsis
  • history
    Sepsis source identified PLUS prior CAD or HFrEF — high pretest probability of mixed septic + cardiogenic phenotype
    sepsis_with_prior_cad_or_hf

Required inputs (9)

  • sbprequired
    vital • used at RED_FLAGS
    Sustained SBP <90 / MAP <65 on NE drives the shock-trigger threshold per SSC 2021 + SCAI 2022
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachy + arrhythmia screen on inotrope titration
  • lactaterequired
    lab • used at RED_FLAGS
    SCAI 2022 staging + SSC 2021 hour-1 bundle marker; trajectory drives inotrope add-on decision when lactate fails to clear despite NE + adequate MAP
  • creatininerequired
    lab • used at CONTEXT
    KDIGO AKI staging + drug dosing (milrinone renal-adjust required)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Type-2 demand mismatch is common in sepsis; helps differentiate primary ACS from SICM/sepsis-driven myocardial injury (4th UDMI 2018)
  • svo2_or_scvo2required
    lab • used at INITIAL_WORKUP
    Central venous saturation — low ScvO2 (<70%) + low MAP confirms low CO state requiring inotrope; distinguishes pure distributive (high ScvO2) from mixed cardiogenic overlap
  • echo_bedsiderequired
    imaging • used at INITIAL_WORKUP
    Serial bedside echo for SICM (global LV dysfunction acute during sepsis), RV function, valvular dysfunction, fluid responsiveness (IVC + LVOT VTI variability)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Exclude primary STEMI / OMI as cause of shock; type-2 ischemia on stress of sepsis common but does not drive cath lab activation
  • sepsis_sourcerequired
    history • used at CONTEXT
    Source identification + control is non-negotiable per SSC 2021 — drives antibiotic spectrum + procedural intervention timing

12-phase flow (11)

  1. 1FRAME
    Mixed septic + cardiogenic shock = sepsis source actively driving distributive collapse PLUS sepsis-induced cardiomyopathy or pre-existing LV dysfunction unmasked. Run BOTH bundles in parallel: SSC 2021 (cultures + abx <60min + lactate + 30 mL/kg + NE) AND CS bundle (echo + inotrope add-on if low CI + cautious volume).
    inputs: sbp, lactate
    advance: Mixed-shock phenotype recognized + dual bundles activated
  2. 2ENTRY
    SSC 2021 hour-1 bundle: lactate + cultures + broad-spectrum abx <60 min + crystalloid 30 mL/kg (cautious if known LVEF <40 or pulmonary edema) + NE for MAP <65 unresponsive
    inputs: sbp, lactate
    advance: Hour-1 bundle complete
  3. 3CONTEXT
    Prior CAD / HFrEF / valvular history; sepsis source + duration; recent antibiotic exposure; baseline volume status; ACEi/ARB on board
    inputs: hr, creatinine, sepsis_source
    advance: Context complete
  4. 4RED_FLAGS
    Failure to clear lactate despite MAP ≥65 AND adequate volume → low CO state requires inotrope add-on (NOT just more NE); rule out cardiac tamponade (especially in septic patients with pericardial effusion)
    inputs: sbp, lactate, svo2_or_scvo2
    actions: cardiogenic_shock, cardiac_tamponade
    advance: Inotrope add-on decision made + tamponade excluded
  5. 5INITIAL_WORKUP
    STAT echo (SICM screen — global LV dysfunction, RV function, fluid responsiveness via IVC + LVOT VTI variability); ECG (exclude STEMI); STAT troponin + BNP; ABG + lactate + ScvO2; sepsis-source workup (CT, US, blood/urine/sputum cx)
    inputs: echo_bedside, ecg, troponin, svo2_or_scvo2, lactate
    actions: sepsis_bundle, cardiogenic_shock, panel.cardiac, panel.renal, panel.abg
    advance: SICM vs primary CS classified + sepsis source identified
  6. 6BRANCHING_WORKUP
    Source control per SSC 2021 (drainage, debridement, line removal, abscess); cardiac cath ONLY if primary ACS pattern on ECG + dynamic troponin + wall-motion abnormality concordant — most septic troponin is type-2 mismatch, NOT culprit lesion
    inputs: ecg, troponin
    actions: acs_pathway
    advance: Source control + ACS rule-out documented
  7. 7RISK_STRATIFICATION
    SCAI 2022 stage + SOFA score + lactate trajectory; SICM independently prognostic — reversibility 7–10d if survival
    inputs: lactate
    advance: Risk stratified
  8. 8TREATMENT
    NE first per SOAP-II (PMID 20200382) titrate to MAP ≥65; ADD low-dose DOBUTAMINE 2.5–5 µg/kg/min EARLY if low CI / low SvO2 / failure to clear lactate despite adequate MAP — do NOT just escalate NE alone (over-vasoconstriction worsens CO in SICM); cautious volume (assess preload responsiveness via passive leg raise / LVOT VTI variability per FENICE methodology); vasopressin 0.03 U/min add-on per SSC 2021 + ADRENAL 2018 hydrocortisone 200 mg/d if persistent NE >0.25 µg/kg/min; SOURCE CONTROL non-negotiable
    inputs: sbp, lactate, svo2_or_scvo2
    actions: protocol.cardiogenic_shock
    advance: Pressor + targeted inotrope + source control active
  9. 9DISPOSITION
    CICU vs MICU vs SICU depending on dominant driver; advanced HF center transfer if persistent shock + non-recoverable LV dysfunction
    advance: Disposition assigned
  10. 10MONITORING
    A-line + central line + serial lactate q1–2h + ScvO2 + UOP hourly; daily echo for SICM recovery (typical 7–10d); abx de-escalation per SSC 2021; cortisol axis if persistent vasopressor dependence
    inputs: lactate
    actions: panel.cardiac, panel.renal
    advance: Monitoring cadence established
  11. 11FOLLOWUP
    Repeat echo at 7–10d to confirm SICM recovery; if persistent LV dysfunction → GDMT initiation per HFrEF pathway (PIONEER-HF cadence); ICU-acquired weakness rehab; post-sepsis syndrome surveillance
    advance: Recovery echo + post-sepsis plan booked