Cardiogenic Shock in the Field
Objective: Recognize pump failure shock, avoid drowning them in saline, and choose a PCI-capable destination when ACS is the story.
Why This Is Hard
BP 78, crackles, JVD, inferior STE. Crews open two large-bores because “shock gets fluid.” AHA/ACC shock and ACS teaching: cardiogenic shock is a pump and afterload problem. Fluids can worsen pulmonary edema. Protocol owns pressors.
- 12-lead. If this is ACS, PCI-capable destination and a STEMI alert beat a hallway bed.
- Sit them up if mentation allows. CPAP only if they protect the airway and BP can tolerate it — see CPAP.
- Pressors/inotropes only if trained and authorized. Push-dose is not a substitute for destination.
Field Rules (Education)
- Picture: hypotension plus congestion (crackles, JVD, edema) or clear lungs with a terrible pump after a big anterior MI.
- Not trauma fluid. Small protocol fluid challenges exist in some cards if they are euvolemic-looking — not a liter dump.
- Right-ventricular infarct: may look dry-hypotensive after inferior STE. Nitrates crash them. See right/posterior MI.
- Mechanical causes (VSD, papillary rupture, tamponade) are hospital diagnoses. You still treat shock and go.
Field Pitfalls
- A liter wide open into crackles.
- Nitro into SBP 70.
- Closest hospital with no PCI when the 12-lead is a STEMI-alert.
Practice
60-second drill
Partner: anterior STE, BP 72, wet lungs, alert. Fluid plan, oxygen/CPAP, destination.
Related: Shock categories, CHF, STEMI.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- 2025 ACC/AHA/ACEP/NAEMSP ACS Guideline — cardiogenic shock and PCI systems of care
- AHA 2025 Part 9: Adult ALS — hypotension after ROSC / peri-arrest support
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.