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cardio.cardiogenic-shock.scai-e.v1PRODUCTION
cardio.cardiogenic-shock.scai-e.v1

Cardiogenic shock — SCAI Stage E (extremis / refractory)

cardiologyacuteadult
Hard-required inputs
0 / 5
Care setting:

Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

SCAI E = cardiac arrest with ongoing CPR/ECMO, OR refractory shock requiring multiple interventions, OR CS-related arrest

Inputs
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Advance rule
Set
Advance when

E-stage criteria met

Patient inputs (5)

E-stage typically MAP <60 despite all interventions; defines extremis

pH <7.2 typical of E-stage extremis; SAVE score input + futility marker

Confirm cardiac etiology + identify reversible causes (tamponade, mechanical) before ECPR

Lactate ≥6-10 mmol/L typical of E-stage; SAVE score input

MAP target ≥65 unattainable on max MCS + pharmacology = E-stage

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningcardiac_arrest_with_ecpr_criteria
    Witnessed VF/VT arrest with bystander CPR <10 min + age <75 + no terminal illness — ECPR candidate
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_cs_on_max_mcs_pharmacology
    MAP <60 + lactate ≥6 + multi-organ failure on Impella/IABP + max pressors + inotropes — VA-ECMO needed
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninglv_distention_on_va_ecmo
    LV distention + pulmonary edema on VA-ECMO due to retrograde aortic flow without LV venting
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningfutility_at_24_72h
    No organ recovery + persistent extremis + SAVE score Class IV-V at 24-72h — futility threshold
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninglimb_ischemia_femoral_cannulation
    Cool/pulseless distal lower extremity on femoral VA-ECMO cannulation despite distal perfusion catheter
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

SCAI E extremis regimen — VA-ECMO + max pharmacology + LV venting; futility cadence
axis: scai_e_extremis_phenotype
Selected axis "SCAI E extremis regimen — VA-ECMO + max pharmacology + LV venting; futility cadence" by default fallback (first axis)
  • norepinephrine
    first line
    alpha_beta_agonist_pressor
    0.5-3.0 mcg/kg/min IV (typical E-stage doses) • IV • continuous
    triggers: e_stage_extremis
    Maintained on max dose during ECMO bridge to recovery or destination
    rxcui 7512
  • epinephrine
    second line
    alpha_beta_agonist_pressor
    0.05-0.5 mcg/kg/min IV • IV • continuous
    triggers: e_stage_persistent_hypotension_on_ne
    Adjunct when NE max + vasopressin inadequate; inotropic + chronotropic at higher doses
    rxcui 3992
  • vasopressin
    second line
    v1_agonist_pressor
    0.03-0.06 U/min IV • IV • continuous
    triggers: e_stage_persistent_hypotension
    V1 adjunct on max NE; often needed at E-stage
    rxcui 11149
  • amiodarone
    comorbidity specific
    class_iii_antiarrhythmic
    150 mg IV bolus then 1 mg/min × 6h then 0.5 mg/min × 18h • IV • continuous
    triggers: e_stage_recurrent_vt_vf, arrest_rhythm_vf_vt
    AHA ACLS Class IIb; preferred during ECPR if VF/VT-arrest etiology
    rxcui 703
  • heparin
    first line
    unfractionated_heparin
    ECMO circuit anticoagulation per protocol; aPTT 60-80 • IV • continuous
    triggers: va_ecmo_deployed
    Mandatory on VA-ECMO to prevent circuit thrombosis; bleeding risk balance
    rxcui 235473

outpatient playbook — drug actions (1)

  1. 1. continue 4-pillar GDMT
    rxcui 593411
    ARNI + BB + MRA + SGLT2i max tolerated • PO • as scheduled
    trigger: Recovered HFrEF
    ACC/AHA 2022 HF Class I (PMID 35363499)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cardiac arrest with ongoing CPR — consider ECPR per ARREST trial criteria; MAP <60 + lactate ≥6 + multi-organ failure on MCS + max pharmacology — E-stage extremis; CS-related arrest with ROSC but persistent extremis — E-stage post-arrest.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — SCAI Stage E (extremis / refractory)** (cardio.cardiogenic-shock.scai-e.v1).
Scope: SCAI E = cardiac arrest with ongoing CPR/ECMO, OR refractory shock requiring multiple interventions, OR CS-related arrest

No severity triggers fired against current inputs.

Plan

Regimen axis: **SCAI E extremis regimen — VA-ECMO + max pharmacology + LV venting; futility cadence**.
1. norepinephrine 0.5-3.0 mcg/kg/min IV (typical E-stage doses) IV continuous (alpha_beta_agonist_pressor, first line) — Maintained on max dose during ECMO bridge to recovery or destination
2. epinephrine 0.05-0.5 mcg/kg/min IV IV continuous (alpha_beta_agonist_pressor, second line) — Adjunct when NE max + vasopressin inadequate; inotropic + chronotropic at higher doses
3. vasopressin 0.03-0.06 U/min IV IV continuous (v1_agonist_pressor, second line) — V1 adjunct on max NE; often needed at E-stage
4. amiodarone 150 mg IV bolus then 1 mg/min × 6h then 0.5 mg/min × 18h IV continuous (class_iii_antiarrhythmic, comorbidity specific) — AHA ACLS Class IIb; preferred during ECPR if VF/VT-arrest etiology
5. heparin ECMO circuit anticoagulation per protocol; aPTT 60-80 IV continuous (unfractionated_heparin, first line) — Mandatory on VA-ECMO to prevent circuit thrombosis; bleeding risk balance

Setting playbook (outpatient) — Long-term: transplant candidacy, advance care planning, cognitive rehab, secondary prevention if recovered
6. continue 4-pillar GDMT ARNI + BB + MRA + SGLT2i max tolerated PO as scheduled — Recovered HFrEF (ACC/AHA 2022 HF Class I (PMID 35363499))

Non-pharmacologic actions:
- Transplant maintenance
- Advance directive completion

AVOID / contraindication checks:
- Ecmo_relative_contraindication_severe_aortic_regurg (LV distention + retrograde flow)
- Ecmo_avoid_terminal_malignancy_unless_bridge_to_recovery (futility)
- Ecmo_avoid_irreversible_brain_injury (ethics)
- Heparin_balance_bleeding_vs_circuit_thrombosis (ECMO standard)

Monitoring

Regimen monitoring:
- pa catheter continuous for lv venting assessment
- q1h lactate and abg to track extremis trajectory
- daily echo for lv recovery and distention
- daily save score for outcome prediction
- daily neuro exam for post arrest brain injury
- limb perfusion q2h femoral cannulation distal perfusion catheter

Setting (outpatient) monitoring:
- Quarterly NT-proBNP + BMP

Follow-up plan: Futility discussion at 24-72h; ethics consult if no recovery; bridge to durable LVAD or transplant if eligible; palliative if not
- Close-out criterion: futility/recovery decision made

Monitoring phase: Continuous PA catheter, daily echo (LV venting + recovery), q1h ABG/lactate, daily SAVE score reassessment, daily SOFA

Disposition

Current setting: outpatient — Long-term: transplant candidacy, advance care planning, cognitive rehab, secondary prevention if recovered

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 or hospice

Escalation triggers (move to higher acuity):
- Recurrent CS → readmit; consider hospice if not transplant candidate

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Witnessed VF/VT arrest with bystander CPR <10 min + age <75 + no terminal illness — ECPR candidate
- [LIFE_THREATENING] MAP <60 + lactate ≥6 + multi-organ failure on Impella/IABP + max pressors + inotropes — VA-ECMO needed
- [LIFE_THREATENING] LV distention + pulmonary edema on VA-ECMO due to retrograde aortic flow without LV venting

Citations

- SCAI 2022 CS staging + AHA 2020 ACLS + 2025 ACC/AHA ACS [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 37634145) [PMID:37634145](https://pubmed.ncbi.nlm.nih.gov/37634145/)
- Cited evidence (PMID 33308475) [PMID:33308475](https://pubmed.ncbi.nlm.nih.gov/33308475/)
- Cited evidence (PMID 25497720) [PMID:25497720](https://pubmed.ncbi.nlm.nih.gov/25497720/)
- Cited evidence (PMID 26333869) [PMID:26333869](https://pubmed.ncbi.nlm.nih.gov/26333869/)

Last reconciled with current guidelines: 2026-05-14.
References