Discuss the assessment and initial management (first hour) of an intubated patient admitted to the ICU with cardiogenic shock, after percutaneous coronary intervention for acute coronary syndrome due to a proximal LAD lesion.
Your answer should include but not be limited to the following headings: potential likely causes, suggested diagnostic approach, key elements of the management of likely causes.
Aim: To allow the candidate to demonstrate familiarity with initial ICU management of cardiogenic shock.
Key sources include: Paper 2019.1 Q1, CanMEDS Medical Expert.
Discussion: This is an exploration of cardiogenic shock post ACS. This SAQ is a repeat, almost identical in content to the 2019 SAQ.
Candidates did well if they addressed the aspects asked in the question and answers focused specifically on the details given.
The expert answer detailed the most likely and relevant causes of shock post PCI for an LAD lesion, with management in the first hour specifically addressing these causes. Elements of management contained in the expert pass include but are not limited to the following:
Candidates are advised to place themselves in the clinical context outlined and describe what they would do, and this would improve their answers.
Candidates who were generic in their answers and who ignored the clinical stem did less well. For example, many candidates answered with a broad differential of all types of shock. Distributive and neurogenic shock is far less likely in the scenario given. The role of PEEP in cardiogenic shock was generally poorly explained and understood. Answers discussing the assessment and initial management should contain elements of prioritization. For example, a bullet point discussion on balloon pumps and the role of emergency CABG would gain more marks than noting the placement of central access and an arterial line.
As the college has pointed out, this SAQ is very close in content to Question 1 from the first paper of 2019. In this case the SAQ design and the examiners' comments were a marked improvement; for example the previous SAQ needed the trainees to discuss cardiogenic shock but did not explicitly state this, so even though cardiogenic shock was obviously their expectation, the question approached it so obliquely that it ended up looking like a generic SAQ about the complications of angiography.
This time the examiners were more direct. The SAQ also gave an expected structure. The patient had an LAD lesion and so right heart stuff is deprioritised in the model answer below, in the interest of saving space:
Potential likely causes of cardiogenic shock in this scenario:
Suggested diagnostic approach:
Key elements of the management of likely causes: