Shock CDI Scenario – August 2021

H&P: 58 yr old male with chest pain and SOB presents to the ER. Troponins ordered along with EKG revealing nonspecific ST changes with rising levels. Cardiology consult for NSTEMI with orders for ASA 325mg x1, Nitropaste, and o2. While waiting on consult, patient became lethargic and pale with fingertip cyanosis noted. Repeated VS showed: 1640: HR 122, RR 18, BP 90/40 (MAP 66); 85/55 (MAP 67), sat 93% RA. 2L NS bolus given with repeat BP of 82/41 (MAP 63) noted at 1755. Dopamine gtt started for patient’s hypotension and patient taken emergently to cath lab for intervention.

Admitting Diagnoses: NSTEMI, HTN, HLD, Hypotension

PMH: Hypertension and Hyperlipidemia

Home Medications: Coreg 12.5 mg BID; Atorvastatin 40 mg QHS

Vitals: Initial: Temp 98.2, HR 103, RR 22, BP 155/82, MAP 124, sat 95% RA

PE: Alert and oriented x3, no JVD, capillary refill <5secs, Tachycardia, Tachypnea, breath sounds clear, Musculoskeletal: 5/5 strength all 4 extremities, anxious with c/o substernal chest pain

Labs: Wbc 10.3, Hgb 13.0, Hct 33.6, Total Cholesterol 221, Triglycerides 92, HDL 27, LDL 130, Troponins (0545) 1st 0.02, (1102) 2nd 0.05, (1713) 3rd 1.14

EKG: Sinus tachycardia with non-specific ST changes

Radiology: CXR: neg

Procedure: 90% blockage of the left anterior descending artery. One Xience drug eluting stent placed to the LAD. Patient transported to CICU for post procedure monitoring and Dopamine gtt monitoring

Discharge Summary: Patient transferred out of CICU the following day without incident after weaning off of Dopamine drip and return of baseline vital signs. Patient to follow up with cardiology as scheduled.

Discharge Medication: Resume previous medications; Fill prescriptions for Isordil, Effient, Plavix, start ASA.

Question: Are there query opportunities based on the scenario stated above?

Discussion: Patient was noted to become lethargic, pale with fingertip cyanosis with increased HR and decreased BP. The patient’s hypotension was refractory to the IV fluid bolus and required initiation of a Dopamine drip and immediate transfer for a cardiac catheterization.

UASI Recommends: Query for Cardiogenic Shock related to NSTEMI

Documentation without Clarification:

  • Principal Diagnosis: NSTEMI (I21.4)
  • Secondary Diagnoses: Hypertension (I10), Hyperlipidemia (E78.5), Hypotension (I95.9)
  • Procedure: PCI with DES (027034Z)
  • Working DRG: 247
  • RW:1.9882      GLMOS:2.1      SOI/ROM: 1/2

Documentation with Clarification:

  • Principal Diagnosis: NSTEMI (I21.4)
  • Secondary Diagnoses: Hypertension (I10), Hyperlipidemia (E78.5), Cardiogenic Shock (R57.0)
  • Procedure: PCI with DES (027034Z)
  • Working DRG: 246
  • RW: 3.1257     GLMOS: 3.9     SOI/ROM: 3/2

CDI Educational Tips:

Cardiogenic shock is the most common cause of death in patients hospitalized with acute myocardial infarction. Presentation is noted with low systolic blood pressure and clinical signs of hypoperfusion. Treatment typically includes immediate intervention with medication, reperfusion, fibrinolytic therapy and emergent percutaneous intervention (PCI) or coronary artery bypass grafting (CABG).  Long term mortality has found to decrease with PCI and/or CABG.

Cardiogenic shock is generally recognized as a systolic blood pressure of less than 90 mmHg for at least 30 minutes, which is related to myocardial dysfunction.  Additional clinical signs may also include:  hypoperfusion, decreased urine output, altered mental status and peripheral vasoconstriction. Typically seen unresponsive to fluids, it often will respond to initiation of inotropes.

Possible clinical indicators of Shock:

  • Vitals:
    • HR >100
    • RR >22
    • BP systolic BP < 90 mmHg or a 30mmHg fall in baseline
  • UOP: <0.5 ml/kg/hr
  • Labs:
    • Lactate >3 mmol/L
    • Base deficit < -4mEq/L
    • pCo2 < 32mmHg


  • Be alert for interventions in the ER record as often shock can initiate and be treated in this setting
  • Be aware of the patient’s baseline blood pressure and compare to current results to see if low readings are significant for the patient
  • Review for inclusion of MAP to help indicate reduced cardiac input
  • Review for possible associated complications of shock, as often, organ damage can result

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.

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