Cardiogenic shock in the emergency department

Meet the patient

A 62-year-old man is 4 hours into an anterior STEMI when the cath-lab is being prepared. He deteriorates in front of you: pale, clammy, mottled from the knees down, BP 74 over 52, HR 130, SpO2 90 per cent on 15 L oxygen, and he has passed 10 mL of urine in the last hour. The JVP is raised, there are bibasal crackles, and the bedside echo shows anterior akinesia with an ejection fraction of 18 per cent. The venous lactate is 6.2 mmol per litre. This vignette is assembled from the trial evidence: most SHOCK-trial infarcts were anterior, the median time from infarct to shock was 5.6 hours, and the mean age at enrolment was 66 plus or minus 10 years. [1]

This is the cold-and-wet phenotype — the Stevenson cold-and-wet — and the spiral is already turning. The two questions that decide his next 30 minutes are the two that decide every cardiogenic shock: what is the cause? (revascularise it) and what is the perfusion? (support it, then unload it). The trap is reaching for a pure alpha-agonist — the pressure number improves while the stroke volume falls and the patient dies.[9]

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