In the ED, their vitals/exam are as above. Patient in cardiogenic shock likely due to acute decompensated heart failure with possible precipitants including myocardial ischemia/infarction, sepsis, dietary indiscretion, medical nonadherence, COPD/PE leading to increased right-sided afterload, renal failure leading to increased preload, hypertensive crisis leading to increased left-sided afterload, arrhythmias, acute valvular dysfunction (endocarditis, MR, AI), worsening aortic stenosis leading to increased left-sided afterload, myocarditis, drugs (BB, CCB, NSAIDs, TZDs), toxins (EtOH, anthracyclines), anemia, or thyroid disease. EKG here with ***. Based on history/exam, I would characterize the patient’s heart failure presentation as {Blank single:19197:: “cold/dry”,”cold/wet”} with the most likely precipitant being ***. Hence, will proceed as below.
– Labs/Tests: Serial EKGs, VBG plus, Lactate, CBC, CMP, Lipase, Troponin x2, BNP, TSH w/ reflex T4, Lipid panel, A1c, PT/INR, Type & Screen, Serum Tox, BCx x2, UA w/ reflex UCx, Urine Tox, COVID-19 RT-PCR. Radial arterial line placement for hemodynamic/gas exchange monitoring. Central venous catheter for access. Will likely need PA line (Swan-Ganz catheter) as inpatient to closely monitor preload (CVP = right-sided, PAP, PCWP = left-sided), contractility (CO, CI, MvO2), afterload (SVR = left-sided, PVR = right-sided, MAP)
– Imaging: CXR, BSUS, TTE as inpatient
– Treatments:
— Escalating Respiratory support: NC -> NRB -> HFNC (No BiPAP given concern for RV failure/pre-load dependence) -> Intubation with in-line norepinephrine/push-dose epinephrine (given intubation will drop preload) +/- inhaled pulmonary vasodilators (improve VQ mismatch by vasodilating good parts off lung) if no evidence of LV failure
— Improve contractility (LV function): Norepinephrine (Inopressor is first line) -> Vasopressin (Pure vasopressor next in line given increases SVR without affecting PVR) -> Inodilator (Dobutamine preferred over Milrinone since quicker onset/easier to titrate) -> Epinephrine (4th line because has shown increased mortality in cardiogenic shock) -> Mechanical support device (Intra-aortic balloon pump, Impella, VA ECMO) if failing despite four pressors
— Optimize preload (volume status): {Blank single:19197:: “Given cold/dry as stated above, will give 250cc bolus and re-assess”,”Given cold/wet as stated above, will diurese with Lasix bolus -> gtt with PRN Diuril for goal 1-2L negative/day with strict I & Os/daily weights”}
— Decrease afterload (blood pressure): Low threshold for inhaled pulmonary vasodilators (reduce afterload by reducing pulmonary pressures) if no evidence of LV failure, Avoid phenylephrine
— Symptom control: Pain control/antiemetics as needed

If thought to be due to AMI, proceed as below:
— Anticoagulation/Antiplatelet: Heparin 60u/kg bolus (5000u max) -> 12U/kg/hr with PTT goal of 63-83, Full ASA 325mg (if not already taken)
— Revascularization: PCI or CABG

If thought to be due to sepsis, proceed as below:
— Antibiotics: Broad-spectrum antibiotics (Vanc/Cefepime/Flagyl)

– Consults: Urgent cardiology consult, Urgent cardiac surgery consult for CABG if patient with history of three-vessel disease
– Dispo: Admission to CCU +/- Cath Lab