What are the SECi (Society of Emergency Medicine and Critical care Interventions) guidelines for managing cardiogenic shock?

Management of Cardiogenic Shock: Evidence-Based Guidelines

All patients with cardiogenic shock require immediate ECG and echocardiography, rapid transfer to a tertiary center with 24/7 cardiac catheterization capabilities, invasive arterial monitoring, and a structured approach prioritizing early revascularization for ACS-related shock, followed by judicious use of inotropes (dobutamine) and vasopressors (norepinephrine) while avoiding routine IABP use. 1

Immediate Diagnostic Assessment

Cardiogenic shock is defined as hypotension (SBP <90 mmHg) despite adequate filling status with signs of hypoperfusion including:

• Oliguria (<0.5 mL/kg/h for ≥6 hours) 1
• Cold peripheries with livedo reticularis 1
• Altered mental status 1
• Lactate >2 mmol/L 1
• Metabolic acidosis 1
• SvO2 <65% 1

Required immediate diagnostics:

• ECG and echocardiography are Class I recommendations for all suspected cardiogenic shock patients 1
• Invasive arterial line monitoring is mandatory (Class I) 1
• Echocardiography must assess ventricular function, valve function, loading conditions, and rule out mechanical complications 1

Transfer and Team-Based Care

Immediate transfer to a tertiary center is essential (Class I recommendation) with:

• 24/7 cardiac catheterization services 1
• Dedicated ICU/CCU with mechanical circulatory support availability 1
• Multidisciplinary shock team including heart failure specialists, critical care physicians, interventional cardiologists, and cardiac surgeons 1

The shock team approach has demonstrated improved 30-day mortality (HR 0.61; 95% CI 0.41-0.93) and reduced in-hospital mortality (47.9% vs 61.0%; P=0.041) 1

Early Revascularization for ACS-Related Shock

For cardiogenic shock complicating acute coronary syndrome:

• Immediate coronary angiography within 2 hours of hospital admission with intent to revascularize (Class I recommendation) 1
• Immediate PCI is indicated if coronary anatomy is suitable (Class I) 1
• If PCI unavailable within 120 minutes, consider fibrinolysis after ruling out mechanical complications (Class IIa) 1
• Complete revascularization during index procedure should be considered (Class IIa) 1

Pharmacologic Management Algorithm

Step 1: Fluid Challenge

First-line treatment if no overt fluid overload present:

• Administer saline or Ringer's lactate >200 mL over 15-30 minutes 1
• Critical caveat: Fluid challenge is contraindicated with signs of overt fluid overload (elevated JVP, pulmonary edema, bibasilar crackles) 2
• In RV infarction, avoid volume overload as it worsens hemodynamics 1

Step 2: Inotropic Support

Dobutamine is the first-line inotropic agent (Class IIb):

• Use to increase cardiac output after adequate fluid resuscitation 1, 2
• Titrate to improve organ perfusion markers: urine output, lactate clearance, mental status 2, 3
• Important limitation: May be ineffective in patients on chronic beta-blocker therapy, particularly carvedilol 1, 2

Alternative: Levosimendan

• Consider especially in patients on chronic beta-blockers 1, 2
• Can be used in combination with vasopressor 1
• Improved cardiovascular hemodynamics in AMI-related shock when added to dobutamine and norepinephrine without causing hypotension 1

Step 3: Vasopressor Support

Norepinephrine is the recommended vasopressor (Class IIb, Level B):

• Use when mean arterial pressure needs pharmacologic support despite inotropes 1, 3
• Preferred over dopamine 1
• Target SBP >90 mmHg and MAP ≥65 mmHg 2, 3
• Administer through central line 3
• Use with caution: Cardiogenic shock typically involves high systemic vascular resistance 3

Epinephrine is NOT recommended:

• Should be restricted to cardiac arrest rescue therapy only 3
• Not recommended as inotrope or vasopressor in cardiogenic shock 3

Step 4: Consider Device Therapy

Rather than combining multiple inotropes, escalate to mechanical support when inadequate response: 1, 2

Mechanical Circulatory Support

IABP is NOT routinely recommended (Class III, Level B):

• The IABP-SHOCK II trial demonstrated no improvement in outcomes for AMI-related cardiogenic shock 1
• May be considered only for mechanical complications (Class IIa) 1

Short-term mechanical circulatory support (Class IIb):

• Consider in refractory cardiogenic shock 1
• Decision based on patient age, comorbidities, neurological function 1
• No current evidence supports one mode over another 1
• Use as bridge to recovery, decision, durable LVAD, or transplant 1

Escalation should be guided by:

• Invasively obtained hemodynamic data when time allows (PA catheterization may be considered) 1
• Multidisciplinary shock team discussion 1
• Patient's overall prognosis, wishes, and therapeutic risk assessment 1

Continuous Monitoring Requirements

Mandatory monitoring parameters (Class I):

• Continuous ECG and blood pressure 1
• Invasive arterial line 1, 3
• Organ perfusion markers: urine output, lactate levels, mental status, SvO2 2, 3

Hemodynamic monitoring considerations:

• No agreement on optimal method including PA catheterization 1
• PA catheter may be considered for confirming diagnosis or guiding therapy (Class IIb) 1
• Treatment guided by continuous monitoring of organ perfusion and hemodynamics 1, 2

Critical Pitfalls to Avoid

1. Do not administer fluid challenge with overt volume overload (elevated JVP, pulmonary edema) 2
2. Do not routinely use IABP - no mortality benefit demonstrated 1
3. Do not use epinephrine except for cardiac arrest 3
4. Do not combine multiple inotropes - escalate to mechanical support instead 1, 2
5. Do not delay revascularization in ACS-related shock - must occur within 2 hours 1
6. Recognize dobutamine ineffectiveness in patients on chronic beta-blockers and switch to levosimendan 1, 2

Treatment Targets

Hemodynamic goals:

• SBP >90 mmHg 2, 3
• MAP ≥65 mmHg 2
• Cardiac index >2 L/min/m² 3

Perfusion markers:

• Urine output restoration 2, 3
• Lactate clearance 2, 3
• Improved mental status 2, 3
• Normalization of SvO2 3