For clinicians · how to use our protocols

Understanding the NMCSN algorithms

One algorithm in two figures, designed to work identically in a critical access hospital and a tertiary ICU. This page explains what each phase asks for, why it asks, and where clinicians most often go wrong.

Why "cardiac trauma"

Trauma care solved a problem cardiogenic shock still has. ATLS gave every clinician a shared entry point — the same primary survey whether the injury is penetrating, blunt, or blast. The algorithm doesn't change with the mechanism; it gives one standardized front door that then adapts to the specific pattern. STEMI systems did the same with ECG-based triage.

Cardiogenic shock has excellent protocols and almost no shared front door — so care varies by ZIP code. The NMCSN algorithm gives shock what trauma already has: a single simple entry point that works at every level of hospital, then branches by etiology rather than by resources.

Source & status. Yau RM, Mitchell R, Bieniarz M, et al. Cardiogenic Shock as "Cardiac Trauma": Building Universal, Equitable Systems of Care — under review at US Cardiology Review, 2026. Figures v2.0, February 2026. Thresholds may change through peer review. Decision support only; not a substitute for your institution's protocols.
ALGORITHM 1Shock Team Activation EMS · ER · referring providers
The trigger — any one is enough
SBP <90sustained ≥15 minutes
Vasopressorsany requirement
Lactate >2mmol/L

You do not need to have decided the cause. The triggers are deliberately crude — they are meant to catch, not to classify.

What we look for

Classic cardiogenic shock

AMIAcute decompensated HF Post–cardiac arrestHigh-risk arrhythmia Post–cardiac surgeryStructural heart disease

…or POCUS-supported, for undifferentiated shock

LV or RV dysfunctionTamponade Massive PESevere valve disease
Do not activate
DNR / comfort-focused care Catastrophic neurologic injury End-stage illness, not eligible for advanced therapies

Hard-wired rather than ad hoc, so shock-team and MCS resources go to patients with realistic recovery potential while respecting patient wishes.

Why — the trauma parallel
This is the ATLS move: one entry point, applied identically whether the patient is an AMI in a cath-capable centre or an undifferentiated hypotensive patient in a rural ED at 2am. Structured POCUS raises diagnostic accuracy in undifferentiated shock from roughly 45–60% on clinical assessment alone to 80–89%.
What to do

A standardized shock call mobilizes the multidisciplinary team — in person, virtual, or hybrid. Norepinephrine first line, vasopressin second. Amiodarone for VT/VF/AF. Avoid calcium channel blockers and beta blockers. Target MAP ≥65 mmHg. Goals: staging within 6 hours of admission; transport to hub within 3 hours when indicated.

Where the call goes. The Level 1 hub is the Heart Hospital of New Mexico: 1-888-727-7646. You reach the shock team, not a switchboard — and you do not need a confirmed diagnosis.
The common miss
Nonischemic and mixed shock — ADHF, PE, tamponade, valve disease, sepsis with cardiac dysfunction — is routinely misclassified as purely distributive and disappears into the sepsis bundle. POCUS is what separates them. And if POCUS suggests distributive or hypovolemic shock, follow the sepsis/other pathway — no shock call.
Walk this algorithm interactively → See the figure →
ALGORITHM 2Assessment & Management Cath lab & ICU
Stage, then act
Stage B — Beginning
SBP <90 OR lactate >2
Early PA catheter; CPO and PAPi; fluid optimization. Inotropes ± diuretics if MAP ≥65.
Stage C — Classic
SBP <90 or on pressors AND lactate >2
pVAD for low CPO despite inotropes.
Stage D/E — Severe
Lactate ≥5 AND MAP <60 on ≥2 pressors ± MCS · OR pH <7.2
VA-ECMO. Consider LV venting (AV closed, pulmonary oedema, EF <30%, LVEDP >20). Assess futility — if not futile, escalate or transfer to a VA-ECMO centre.

Across all stages: PA catheter with CPO, RAP and PAPi — and etiology-specific treatment:

Revascularize ACSOptimize volume Relieve PE / tamponadeValve intervention Arrhythmia management
The ICU loop

Reassess hemodynamics and lactate every 6–12 hours. Targets: CPO ≥0.6 W, lactate <4, stable MAP and urine output. Then branch: Wean (CPO >0.6 + lactate <4) · Monitor (CPO <0.6 + lactate <4) · Escalate (CPO <0.6 + lactate >4 — and assess futility). Escalation options: VA-ECMO, Impella 5.5/CP, durable LVAD.

The hard rule
No patient leaves the cath lab for the ICU hypotensive, tachycardic, volume-overloaded, or on vasopressor/inotrope support without bedside POCUS, a PA catheter, shock-team consultation, and an explicit discussion of escalation.
Why — the trauma parallel
Trauma doesn't treat every injury the same way, but it assesses every injury the same way. The hemodynamic backbone is the shared assessment; etiology drives what actually gets done — so ACS is never under-treated and no single nonischemic cause gets disproportionate emphasis. And the exit strategy is explicit: when thresholds aren't met despite maximal therapy, the algorithm directs the team toward durable options or palliative-focused care rather than open-ended support — a decision that otherwise gets made by default.
The common miss
Most cath-lab shock protocols were built around AMI. The harder discipline is applying the same hemodynamically guided approach across the full etiologic spectrum — the place where a mixed-etiology patient quietly gets managed as though they were an AMI.
Stage a patient with the interactive tool → See the figure →

What is universal, what is adaptable

This distinction is why the algorithm travels. The backbone doesn't change between a 25-bed critical access hospital and a tertiary centre; everything hung on the backbone does.

Universal — never changes

Same in every hospital, every shift
  • Hemo-metabolic triggers
  • POCUS to classify undifferentiated shock
  • SCAI-based staging
  • CPO/lactate branch points
  • Explicit futility assessment and goals-of-care integration
  • The standardized shock call

Locally adaptable

Built around the backbone, not into it
  • Staffing — in-person, virtual, or hybrid shock teams
  • Device selection, by availability and expertise
  • Transport logistics and hub–spoke relationships
  • EMS integration

A critical access hospital with no cath lab can run the entire universal column — apply the triggers, do the POCUS, start vasoactive support, and activate transfer. Participation doesn't require capability. That is the point.

Yau RM, Mitchell R, Bieniarz M, et al. Cardiogenic Shock as "Cardiac Trauma": Building Universal, Equitable Systems of Care. Submitted to US Cardiology Review (2026), under peer review; algorithm figures v2.0, February 2026. POCUS accuracy figures per the manuscript's cited sources. This page is education and decision support only — it does not replace clinical judgment or institutional protocol, and no patient data is stored or transmitted.