NMCSN Protocols Staging tool Patients & families Should this be a shock call?

NMCSN · Six screens, about four minutes

Understanding
cardiogenic shock

Where the field has been, what the landmark trials taught us — often by failing — why shock still hides, how it is treated, and what we are building in New Mexico.

Scroll, or use ↓  ·  one screen per chapter ↓

Chapter one

Two plateaus and one step

Cardiogenic shock is the heart failing as a pump, so profoundly that the body begins to shut down. From the 1970s through the 1990s, mortality sat near 70–80% and barely moved.

In 1999 the SHOCK trial showed that opening the artery emergently saved lives. Mortality fell — then stalled again near 40–50%, where it has stayed for twenty years.

100%75% 50%25% 19751999 Today 70–80% died40–50% SHOCK trialearly revascularisation and still there
Schematic, not a pooled analysis — the shape of the published record: a long plateau, one real step down, then a second plateau.

Chapter two

Four trials. Three said no.

The last fifteen years have been humbling. Each trial tested something that seemed obvious.

Read together they say one thing: no single device rescues shock — systems do.

2012 · IABP-SHOCK II · no benefit

Intra-aortic balloon pump

Decades of use on physiologic faith; randomised, no survival benefit. Plausibility is not proof.

2017 · CULPRIT-SHOCK · less was better

Fixing every artery at once

Culprit-only beat immediate complete revascularisation. In a crashing patient, less — done fast — can be more.

2023 · ECLS-SHOCK · no benefit

Routine VA-ECMO for AMI shock

ECMO for everyone did not save lives. The most powerful machine isn't automatically the right one.

2024 · DanGer Shock · mortality benefit

Microaxial flow pump, selected patients

First device to reduce 180-day death — in carefully selected patients, with more complications. Selection, timing and teams are the active ingredient.

Chapter three

Why it hides

There is no single test. Early on, blood pressure can be normal while the organs are quietly failing. Lactate is the smoke detector.

Shock is a spectrum, not a switch — patients slide down a spiral, and every loop is harder to exit. In New Mexico a fourth problem compounds it: geography. A diagnosis made after the transfer window closes arrives late.

ABC DE At riskBeginningClassic DeterioratingExtremis Catch it here Not here
Low cardiac output Hypoperfusion · lactate ↑ Pump weakens further Myocardial ischaemia each loop harder to exit
The spiral is why timing dominates everything else.

Chapter four

A ladder, not a reflex

Three things at once: fix the cause, support the circulation (norepinephrine first, MAP ≥65), and track perfusion with serial lactate — the pressure can lie; the lactate rarely does.

Then measure the pump, not the pressure: CPO and PAPi say how much reserve is left and which ventricle is failing. In the ICU, reassess every 6–12 hours — wean, monitor, or escalate.

Inotropes / pressorspVADVA-ECMO if MAP ≥ 65 low CPO despiteinotropes the sickest; vent the LVif it cannot eject Every rung goes in with an exit strategy recovery  ·  durable LVAD  ·  transplant
Escalating without an exit strategy is how a patient ends up supported with nowhere to go.

Chapter five

Treat it like trauma

Universal triggers any clinician can apply, one standardised shock call, tiered hospitals, and clocks — staging within 6 hours, transport within 3.

37.6% → 59.4%

30-day survival, first five years (313 patients, 2019–2024). Patients transferred from rural hospitals did as well as those arriving at the hub directly. Geography stopped predicting death.

One number works statewide.

Reaches the shock team at the Heart Hospital of New Mexico. Concern from the bedside is enough.

1-888-727-7646Level 1 Hub Transfer
GallupFarmington Las CrucesEspañolaRoswell HUB Level 1 One call. One protocol. Staging < 6 h · transport < 3 h No referral or diagnosis needed
Spoke sites shown are illustrative of the model, not a complete roster.

Everything we build is free and open.

Educational overview — not medical advice. Trials summarised from the published literature (SHOCK 1999; IABP-SHOCK II 2012; CULPRIT-SHOCK 2017; ECLS-SHOCK 2023; DanGer Shock 2024). NMCSN outcomes are from our statewide cohort, under review at JSCAI.