ALGORITHM FOR CARDIOGENIC SHOCK
Cardiogenic shock results from impaired cardiac output, leading to inadequate tissue perfusion despite sufficient intravascular volume. Unlike hypovolemic or distributive shock, fluid resuscitation must be used cautiously, as excessive fluids can worsen pulmonary edema.
Key Goals of Cardiogenic Shock Management:
Optimize oxygenation and ventilation. Use cautious fluid administration (if needed). Administer inotropes to support cardiac output. Identify and treat the underlying cause.
RECOGNITION: SIGNS OF CARDIOGENIC SHOCK
Key Signs of Cardiogenic Shock:
- Tachycardia (often severe).
- Weak pulses, cool extremities, delayed capillary refill.
- Hepatomegaly (right heart failure).
- Jugular venous distension (JVD) (in older children).
- Pulmonary edema (crackles, tachypnea, respiratory distress).
- Hypotension (late sign).
Cardiogenic vs. Hypovolemic Shock:
- Pulmonary edema = Cardiogenic shock.
- No lung congestion + dry mucous membranes = Hypovolemic shock.
MANAGEMENT ALGORITHM FOR CARDIOGENIC SHOCK
Step 1: Provide High-Flow Oxygen and Support Ventilation
100% oxygen via non-rebreather mask. If respiratory distress worsens, consider non-invasive ventilation (CPAP/BiPAP). For severe cases: Endotracheal intubation and mechanical ventilation.
Intubation increases afterload—use caution and optimize preload before intubation.
Step 2: Establish Vascular Access (Use Fluids Cautiously!)
Peripheral IV or IO access as soon as possible. Fluids: 5-10 mL/kg bolus (not 20 mL/kg as in other shock types). Reassess before giving additional fluids—watch for pulmonary congestion.
Do NOT give large-volume fluid resuscitation unless there is clear hypovolemia!
Step 3: Administer Inotropes to Improve Cardiac Output
First-Line Inotropes for Cardiogenic Shock:
| Drug | Dose | Effect |
|---|---|---|
| Epinephrine | 0.1-0.3 mcg/kg/min IV infusion | Increases contractility and cardiac output |
| Dopamine | 5-10 mcg/kg/min IV infusion | Improves cardiac output and perfusion |
| Dobutamine | 5-20 mcg/kg/min IV infusion | Increases cardiac contractility, reduces afterload |
Dopamine (low-moderate dose) is first-line for mild cases. Epinephrine is preferred in severe cases with poor cardiac output.
Avoid high-dose dopamine (>10 mcg/kg/min) in severe shock—it may cause excessive vasoconstriction and worsen perfusion.
Step 4: Identify and Treat the Underlying Cause
Common Causes & Treatments:
Cause Management
Congenital Heart Disease (Ductal-Dependent Lesions) Start Prostaglandin E1 (PGE1) to keep the ductus arteriosus open
Myocarditis Supportive care, inotropes, avoid excess fluids
Arrhythmias (Bradycardia, SVT, VT) Manage per PALS arrhythmia guidelines (e.g., adenosine, synchronized cardioversion)
Severe Hypertension (Hypertensive Crisis) Consider nitroprusside or nicardipine infusion
If congenital heart disease is suspected, prostaglandins (PGE1) are critical to maintain circulation!
QUICK REFERENCE: PEDIATRIC CARDIOGENIC SHOCK MANAGEMENT
Step Action Key Considerations
1 Oxygen & Ventilation High-flow O₂, CPAP/BiPAP, consider intubation
2 IV/IO Access Use fluids cautiously (5-10 mL/kg boluses)
3 Inotropes Epinephrine or Dopamine to improve cardiac output
4 Identify Cause Ductal-dependent lesion? Myocarditis? Arrhythmia?
WHEN TO ESCALATE BEYOND STANDARD TREATMENT?
If shock persists despite fluids and inotropes:
Condition Next Steps
Severe Myocardial Dysfunction Consider Milrinone (0.25-0.75 mcg/kg/min)
Persistent Shock Despite Inotropes Consider Mechanical Circulatory Support (ECMO)
Severe Arrhythmia Follow PALS arrhythmia guidelines
Ductal-Dependent CHD Immediate PGE1 infusion, consult cardiology
Consider ECMO for severe, refractory cardiogenic shock!
SIGNS OF IMPROVEMENT AFTER TREATMENT
Heart rate normalizes. Strong pulses, improved capillary refill (<2 sec). Improved oxygenation (SpO₂ >94%) and breathing. Stable blood pressure and urine output >1 mL/kg/hr.
If these signs are absent, escalate to advanced interventions (ECMO, additional inotropes).
SUMMARY: WHY TIMELY MANAGEMENT OF CARDIOGENIC SHOCK MATTERS
Cardiogenic shock requires cautious fluid resuscitation—too much can worsen pulmonary edema. Inotropes (epinephrine, dopamine, dobutamine) are the cornerstone of treatment. Identifying and treating the underlying cause (CHD, myocarditis, arrhythmia) is critical. Early escalation to mechanical support (ECMO) may be life-saving in severe cases.
Takeaway: Pediatric cardiogenic shock is a high-risk condition—early recognition and appropriate inotropic support can dramatically improve survival.