Cardiogenic shock

Diagnosis: The cardiogenic shock from the acute anterior STEMI — the infarct (the chest pain, the ECG), the pump failure (the hypotension at the systolic 76), the tissue hypoperfusion (the cold peripheries, the oliguria), and the raised filling pressures (the pulmonary oedema). This is the cold and wet phenotype of the cardiogenic shock.

Assessment: ABCDE, the oxygen, the intravenous access, the arterial line, the urinary catheter. The 12-lead ECG (the anterior STEMI), the troponin, the lactate (the hypoperfusion and the clearance), the blood gas (the acidosis), the renal and the liver function. The point-of-care echocardiography (the poor left ventricular function, the regional wall motion abnormality, the exclusion of the mechanical complication) and the lungs (the B-lines of the oedema) and the IVC (the full).^[1]

Management:

1. The oxygen and the non-invasive ventilation for the pulmonary oedema (the CPAP reduces the preload and the afterload and improves the oxygenation). The intubation for the respiratory failure.
2. The fluids cautiously — this patient is wet (the pulmonary oedema), so NO large boluses; the small boluses only with the reassessment.
3. The inotrope (the dobutamine) for the low output, and the vasopressor (the noradrenaline) for the hypotension.
4. The EARLY coronary revascularisation — the coronary angiography and the primary PCI of the culprit lesion (the CULPRIT-SHOCK). This is the definitive, the mortality-reducing treatment, and it must NOT be delayed to stabilise the patient — the shock resolves with the reperfusion.
5. The mechanical circulatory support in the capable centre (the VA-ECMO, the microaxial flow pump) as the bridge. The intra-aortic balloon pump is NOT recommended (the IABP-SHOCK II — no benefit).
6. The multidisciplinary shock team, the cardiology and the intensive care.

Disposition: The catheter laboratory, then the intensive care.