Cardiogenic shock results from decreased cardiac output due to pump failure. It can be caused by primary myocardial injury, arrhythmias, cardiomyopathy, myocarditis, congenital heart disease, sepsis, or poisoning. Symptoms include tachypnea, tachycardia, cool extremities, declining mental status, and decreased urine output. Management involves rapid diagnosis, restoration of coronary blood flow, complication management, and maintenance of end-organ function. Outcomes depend on the cause, but mortality exceeds 50% making aggressive treatment critical.

1. • Cardiogenic shock — Cardiogenic shock results from pump failure,
manifested physiologically as decreased systolic function and
depressed cardiac output .
• Cardiogenic shock is uncommon among children as compared
with adults, among whom ischemic heart disease is the major
cause.
• Cardiac causes may result from inadequate contractility or
excessively fast or slow rhythms:
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Cardiogenic Shock

2. Etiology
• Primary myocardial injury,
• Arrhythmias,
• Cardiomyopathy,
• Myocarditis,
• Congenital heart disease with heart failure, before or after
surgery, including heart transplantation
• Sepsis,
• Poisoning.
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3. • Ventricular fibrillation and pulseless ventricular
tachycardia abolish cardiac output, while diminished
ventricular filling time.
• Prolonged unrecognized supraventricular tachycardia .
• Bradyarrhythmias and complete heart block can result
in shock caused by chronotropic insufficiency.
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Arrhythmias

4. Blunt cardiac injury
Myocardial contusion
Traumatic aneurysm
Traumatic septal defect
Chamber rupture
Valvular rupture
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5. • Drug toxicity : Beta blockers, Barbiturates, Chemotherapeutic agents,
Calcium channel blockers
• Metabolic derangements : Acidosis,Hyperkalemia ,Hypocalcemia
• Hypothermia
• Hypoxic or anoxic/ischemic injury
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Others ....

6. History
 Cardiogenic shock – History of heart disease , history
of palpitations, signs of heart failure.
 Infant : poor feeding, poor appetite and can quickly
progress to lethargy ,
Older child : fatigue ,difficulty of breathing or chest
pain , as shock progress may experience syncope .
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7. The presenting signs.
• Tachypnea, Tachycardia,
• Cool extremities, delayed capillary filling time,
• Poor peripheral and/or central pulses,
• Declining mental status, coma
• Decreased urine output,
• Raised JVP ,crackles, hepatomegally,
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8. • Mortality exceeds 50% so focus on :
• Rapid diagnosis,
• Restoration of coronary blood flow through early revascularization,
• Complication management, and
• Maintenance of end-organ homeostasis.
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Management

9. Management
• Initial resuscitation
 stabilizing the airway ,breathing, circulation with
establishment of vascular access
 continues monitoring of vital signs, pulse oximetry
saturation
 chest compression indicated for bradicardia with
poor perfusion
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10. In uncompensated cardiogenic shock
NS bolus 5-10ml /kg over 10 to 20 mins
Dopamine 10mcg/kg/min and/or Doubutamine 10-
15mcg/kg/min infusion.
 Mechanical ventilation if patient in respiratory
distress or critically ill.
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11.  In compensated cardiogenic shock
Frusamide infusion 0.05-0.1mg/kg/h
Add milirnon 0.1 -1mcg/kg/min
Increased afterload state
Chx by normal HR, good central pulse, weak peripheral
pulse, cold periphery, BP normal to high, hyperlactemia
Increase infusion rate of milirnon.
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12. • After milirnon infusion : tachycardia, good pulse,
warm periphery, decrease UOP, slightly low BP and
hyperlactemia consider hypovlumia and administer 5-
10ml/kg fluid bolus
• When optimal cardiac out put is achieved: good
normal pulse, warm extremity, good UOP, normal BP
and normal lactate maintain the same inotropic
support.
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13. Treatment of Precipitating factor
Arrhythmia,
Drug toxicity ,
Underlying infection,
Anemia,
Metabolic derangements,
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14. Distributive shock
• Refers to a condition in which systemic vascular
resistance is initially decreased.
• It may occur as the result of sepsis, anaphylaxis, or
neurologic injury.
• Associated with increased capillary permeability with
loss of plasma from the intravascular space into the
tissues.
• Significant decreases in both preload and after load
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15. Anaphylacyic shock
 Cutaneous : sudden onset of generalized urticaria,
angioedema, flushing, pruritus.
• However, 10 to 20% of patients have no skin findings.
 Respiratory : Stridor and wheezing
 Cardiovascular : Decreased Blood Pressure
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16. • Air way management
 Place patient in recumbent position, if tolerated, and elevate lower
extremities.
 Immediate intubation if evidence of impending airway obstruction from
angioedema.
 Oxygen: Give 8 to 10 L/minute via facemask or up to 100% oxygen, as
needed.
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Management

17. • Fluid managment
 Normal saline rapid bolus: Rapid infusion of 20 mL/kg. Re-evaluate and repeat
fluid boluses (20 mL/kg), repeat as needed.
• Epinephrine
 IM epinephrine (1 mg/mL preparation): 0.01 mg/kg should be injected
intramuscularly in the mid-outer thigh. the maximum is 0.5 mg per dose. If
there is no response or inadequate, it can be repeated in 5 to 15 minutes
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18. Treatment of Refractory symptoms:
• Epinephrine infusion: In patients with inadequate response to IM
epinephrine and IV saline, give epinephrine continuous infusion at 0.1 to
1 mcg/kg/minute, titrated to effect.
• Vasopressors: Patients may require large amounts of IV crystalloid to
maintain blood pressure and may require a second vasopressor
• Albuterol: For bronchospasm resistant to IM epinephrine, give albuterol
0.15 mg/kg (minimum dose: 2.5 mg) in 3 mL saline via nebulizer. Repeat,
as needed.
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19. Obstructive shock
• Describes physical obstruction of systemic blood flow
from the heart which causes abrupt impairment of
cardiac output.
• The acute presentation may quickly progress to
cardiac arrest.
• Children with severe respiratory distress and signs of
circulatory compromise may have obstructive shock.
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20. Etiology
• Tension pneumothorax,
• Cardiac tamponade,
• Hemothorax,
• Pulmonary embolism,
• Ductal-dependent congenital heart defects
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21. Management
 Adressing the primary insult
 pericardiocentesis for pericardial effusion
 pleurocentesis for pneumothorax
 Thrombectomy/thrombolysis for pulmonary embolism
 prostaglandin infusion for ductus-dependent cardiac lesions.
 Fluid resuscitation
 There is often a “last-drop” phenomenon associated with some
obstructive lesions.
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22. Shock in SAM patients
• Sunken eyes, lethargy, and tenting of skin may occur from malnutrition
alone and can cause clinicians to overestimate the degree of
dehydration.
Diagnosis of Shock
 lethargic or unconscious and cold hands
• Plus either:
 slow capillary refill (longer than 3 sec) or weak fast pulse.
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23. Management
 Give oxygen
 Give sterile 10% glucose (5 mL/kg) by IV
 Give IV fluid at 15 mL/kg over 1 hr, if improvement isues repeat IV 15
mL/kg for 1 more hr.
 Switch to oral or nasogastric rehydration with ReSoMal, 5-10 mL/kg
alternate hr with F-75 until fully rehydrated.
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24. Refractory cases
If there are no signs of improvement : ? Septic
Give maintenance fluid IV (4 mL/kg/hr) while waiting for
blood
Transfuse 10 mL/kg fresh whole blood slowly over 3 hr. If
signs of heart failure, give 5-7 mL/kg packed cells .
Give furosemide 1 mL/kg IV at the start of the transfusion
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25. PITFALLS
 Failure to recognize nonspecific signs of compensated shock
 Inadequate monitoring of response to treatment
 Inappropriate volume for fluid resuscitation
 Failure to reconsider possible causes of shock for children who are getting
worse.
 Failure to recognize and treat obstructive shock.
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27.  A 5 year old child is brought to the ED after sustained
blunt chest trauma on P/E he is conscious, no bleeding
from any site ,V/S BP is 60/40, PR =80 bts/min ,RR=45
brths/min , T=36.6 c , SPO2 70%
Capillary refill is <2sec ,
Resp : IC / SC Retraction, Hyperesonant left chest ,
Tracheal shift to the right .
Cvs : Distended neck vein
How do you manage ?
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28. Clinical Trial
• However, evidence suggests that the WHO
recommendations for fluid resuscitation in severely
malnourished may be too restrictive. For example, in
an observational study of fluid resuscitation in 149
severely malnourished children with cholera and
severe dehydration, infusion of approximately 20
mL/kg per hour of an isotonic saline solution over four
to six hours was not associated with heart failure in
any patient, and all patients survived .
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29. Reference
• Up-to-date
• Nelson 2021 edition
• Pediatrics Advanced life support guideline
• SAM guideline 2020 , 3rd edition
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