C25. Cardiogenic shock in a 25-year-old male with tombstone ST-segment elevation pattern in emergency department, early hemodynamic assessment to guide the management: a case report of mixed cardiogenic shock phenotype

Abstract

Abstract Background Cardiogenic shock (CS) is a lethal condition. There are several phenotypes, and classification based hemodynamic and/or clinical parameters for CS. We present CS with tombstone ST-segment elevation in emergency department (ED) with assessment of hemodynamic using bedside ultrasound to classify and guide the management. Case Description A 25-year-old-male complained sense of fatigue, fever, and myalgia for 2 days. The initial blood pressure and SpO2 were unrecordable, heart rate 112x/m, respiration rate 28x/m, temperature 36.8 °C. The patient was pale, anxious, with difficult jugular venous pressure assessment due to overweight appearance, diminished S1, and cold extremity. Electrocardiogram revealed tombstone ST-elevation in V2-V6, I, and aVL. After oxygenation management, initial dobutamine and norepinephrine, we performed bedside cardiac ultrasound revealed anterior left ventricular wall hypokinesis, mild pericardial effusion, ejection fraction 52%, mitral E/A ratio 2.7, E deceleration time 90.82ms, positive lung B-lines, inferior vena cava diameter 2.14cm with collapsibility <50%. Tricuspid annular plane systolic excursion 19mm. Estimated cardiac index 1.88L/m/cm2, and systemic vascular resistance (SVR) 775dynes.sec/cm5. This pattern suggests mixed CS phenotype. Vasopressor was up titrated with improved blood pressure, SpO2, and urinary output. CXR revealed cardiomegaly, troponin T > 10.000pg/ml. The patient was successfully stabilized in ED and transferred to ICCU. Discussion We classify our case as mixed CS. With hemodynamic assessment, we can determine the character of the shock with more objective parameters, guide the treatment, and avoiding over (increase oxygen demand, afterload, arrhythmia) and underused of vasopressor to bridging the treatment of causative factor.