PALS Provider: Course
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
- Tachycardia (often severe)
- Weak pulses, cool extremities, delayed capillary refill
- Hepatomegaly (right-sided heart failure)
- Jugular venous distension (in older children)
- Pulmonary edema (crackles, tachypnea)
- Hypotension (late and ominous sign)
Cardiogenic vs. Hypovolemic Shock: Pulmonary edema suggests cardiogenic shock. Clear lungs with dry mucous membranes favors hypovolemia.
Management Algorithm for Cardiogenic Shock
- Step 1: Oxygen and Ventilation
- Administer 100% oxygen via non-rebreather mask.
- Consider non-invasive support (CPAP/BiPAP).
- Intubate for severe distress or hypoxia, with caution. - Step 2: Vascular Access and Cautious Fluids
- Establish IV or IO access.
- Administer 5–10 mL/kg isotonic fluid bolus over 10–20 minutes.
- Reassess frequently. Avoid excess volume. - Step 3: Administer Inotropes
| Drug | Dose | Effect |
|---|---|---|
| Epinephrine | 0.1–0.3 mcg/kg/min IV infusion | Increases contractility and output |
| Dopamine | 5–10 mcg/kg/min IV infusion | Improves perfusion in mild cases |
| Dobutamine | 5–20 mcg/kg/min IV infusion | Boosts cardiac output, lowers afterload |
Note: Avoid high-dose dopamine (>10 mcg/kg/min) due to risk of excessive vasoconstriction.
- Step 4: Identify and Treat the Underlying Cause
| Cause | Management |
|---|---|
| Ductal-dependent congenital heart disease | Initiate Prostaglandin E1 (PGE1) |
| Myocarditis | Inotropes, avoid excess fluids, supportive care |
| Arrhythmias (SVT, bradycardia, VT) | Treat per PALS algorithm (e.g., adenosine, synchronized cardioversion) |
| Hypertensive crisis | Use nitroprusside or nicardipine infusion |
Quick Reference: Pediatric Cardiogenic Shock Management
| Step | Action | Key Considerations |
|---|---|---|
| 1 | Oxygen & Ventilation | Use CPAP/BiPAP or intubate with caution |
| 2 | IV/IO Access | Fluids limited to 5–10 mL/kg boluses |
| 3 | Inotropes | Dopamine, Epinephrine, Dobutamine |
| 4 | Identify Cause | CHD, myocarditis, arrhythmia, hypertension |
When to Escalate Beyond Standard Treatment
| Condition | Next Steps |
|---|---|
| Severe myocardial dysfunction | Initiate milrinone (0.25–0.75 mcg/kg/min) |
| Persistent shock despite inotropes | Consider ECMO |
| Unstable arrhythmia | Follow PALS arrhythmia protocol |
| Ductal-dependent lesion | Start PGE1, consult pediatric cardiology |
Signs of Improvement After Treatment
- Heart rate normalizes
- Capillary refill <2 seconds
- Strong central pulses
- SpO₂ >94%, improved breathing
- Stable BP and urine output >1 mL/kg/hr
Summary: Why Timely Management of Cardiogenic Shock Matters
- Cautious fluids are essential—avoid worsening pulmonary edema
- Inotropes are the cornerstone of therapy
- Identify and treat underlying causes early
- Escalate to ECMO if refractory shock develops
Takeaway: Pediatric cardiogenic shock is a high-risk condition. Early recognition and inotropic support are essential to survival.