Cardiogenic shock and mechanical circulatory support — structured clinical encounter

Structured encounter testing the approach to a six-year-old boy who presents three days after a viral illness in compensated cardiogenic shock from fulminant myocarditis: the bedside distinction from distributive shock through the presence of congestion, the cautious-fluid principle and the inotrope resuscitation, the SCAI staging, the recognition of refractory shock, the escalation to venoarterial extracorporeal membrane oxygenation as a bridge to recovery, and the family conversation about the goal and prognosis of support and the complication burden.

structured clinical encounter

Prompt

A previously well six-year-old boy presents to the emergency department three days after a febrile respiratory illness. He is cold and mottled with weak pulses, a capillary refill of four seconds, oliguria and a gallop rhythm. His blood pressure is 95/60 mmHg (normal for age), his respiratory rate is 42, and his lactate is 5.2 mmol/L. The electrocardiogram shows widespread ST and T-wave changes. The echocardiogram shows a globally hypokinetic left ventricle with a moderate pericardial effusion but no tamponade physiology. You are the paediatric registrar working through the recognition, resuscitation, escalation and family conversation.

Encounter structure

The candidate works through the case in five phases: [2]

Recognition and differential (5 minutes): Identify cardiogenic shock from the low-output signs (cold mottled peripheries, weak pulses, prolonged capillary refill, oliguria, a rising lactate) alongside the congestion (gallop rhythm, and hepatomegaly if present); explain why the normal blood pressure does not exclude shock; distinguish cardiogenic from distributive shock at the bedside through the presence of congestion and the absence of warm peripheries; anchor the diagnosis on the echocardiogram and the electrocardiogram, and exclude a disease-specific rescue (tamponade, duct-dependent lesion, tachyarrhythmia). [13] [2]
Initial resuscitation and staging (5 minutes): Give oxygen and ventilatory support; establish two reliable lines; state the cautious fluid strategy of five-to-ten millilitre-per-kilogram aliquots with reassessment for congestion after each, deliberately contrasting it with the ten-to-twenty millilitre-per-kilogram boluses of septic shock; start an inotrope (milrinone, dobutamine, adrenaline or noradrenaline) titrated to perfusion and the lactate trend; assign the SCAI stage and state the trigger for mechanical support; arrange early retrieval to a paediatric cardiac intensive care centre. [12] [11]
The refractory deterioration (5 minutes): Six hours later the blood pressure falls and the lactate rises despite inotropes; recognise refractory cardiogenic shock (SCAI stage D to E); state that the definitive intervention is venoarterial extracorporeal membrane oxygenation as the first-line rescue device, deployed early before irreversible end-organ failure. [10] [8]
The family conversation (5 minutes): Explain that fulminant myocarditis is a bridge to recovery and that the inflamed myocardium often recovers near-normal function once supported through the storm; present the complication burden honestly — bleeding and thromboembolic stroke from mandatory anticoagulation, infection, haemolysis and limb ischaemia; frame the device as temporary support with the expectation of recovery and explant, in contrast to the bridge-to-transplant pathway of cardiomyopathy. [7] [15]
Disposition and follow-up (5 minutes): Outline the disposition to a paediatric cardiac intensive care unit with mechanical circulatory support and transplant capability through the regional retrieval service; describe the weaning and explant pathway for recovered myocarditis; and contrast the recovery pathway with the durable ventricular assist device pathway of a child with cardiomyopathy (Berlin Heart EXCOR for small children, HeartMate 3 for larger), naming the four goals of support. [3] [6]

References

[1]Amdani S; Rossano JW; Wilmot I; et al Evaluation and Management of Chronic Heart Failure in Children and Adolescents With Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circulation, 2024.PMID 38808502
[2]Baran DA; Grines CL; Bailey S; et al SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society for Cardiovascular Angiography and Interventions (SCAI), and the Society of Thoracic Surgeons (STS). Catheter Cardiovasc Interv, 2019.PMID 31104355
[3]Fraser CD Jr; Jaquiss RD; Rosenthal DN; et al Prospective trial of a pediatric ventricular assist device. N Engl J Med, 2012.PMID 22873533
[4]Fraser CD Jr; Jaquiss RD The Berlin Heart EXCOR Pediatric ventricular assist device: history, North American experience, and future directions. Ann N Y Acad Sci, 2013.PMID 23750961
[5]Almond CS; Morales DL; Blackstone MH; et al Berlin Heart EXCOR Pediatric ventricular assist device Investigational Device Exemption study: study design and rationale. Am Heart J, 2011.PMID 21884857
[6]Rihal CS; Naidu SS; Givertz MM; et al 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care. J Card Fail, 2015.PMID 26036425
[7]Assmann A; Boekstegers P; Brcic I; et al Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure -A clinical practice guideline. ESC Heart Fail, 2022.PMID 34811959
[8]Bembea MM; Agus M; Akcan-Arikan A; et al Extracorporeal Membrane Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs. Pediatr Crit Care Med, 2023.PMID 36995097
[9]Bhaskar P; Dhar R; Stephenson AL; et al Use of ECMO for Cardiogenic Shock in Pediatric Population. J Clin Med, 2021.PMID 33917910
[10]Sachdev A; Chauhan S; Gupta D; et al Refractory pediatric cardiogenic shock: A case for mechanical support. Indian J Crit Care Med, 2016.PMID 27994387
[11]Schranz D Pharmacological Heart Failure Therapy in Children: Focus on Inotropic Support. Handb Exp Pharmacol, 2020.PMID 31707469
[12]Burkhardt BEA; Rucker G; Stiller B Inotropes for the prevention of low cardiac output syndrome and mortality for paediatric cardiac surgery patients. Cochrane Database Syst Rev, 2024.PMID 39588800
[13]Rossano JW; Cherng An V; Lin KY; et al Heart failure in children: etiology and treatment. J Pediatr, 2014.PMID 24928699
[14]Esangbedo ID; Biagas KV; Ma X; et al Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review. Pediatr Crit Care Med, 2020.PMID 32345933
[15]Feng T; Zhao Y; Li L; et al Clinical outcomes of VA-ECMO in children with fulminant myocarditis: a single-centre case series. BMC Pediatr, 2026.PMID 42056983
[16]Levin A Levosimendan. J Pediatr Intensive Care, 2013.PMID 31214430

Cardiogenic shock and mechanical circulatory support — structured clinical encounter

structured clinical encounter

References

[1]Amdani S; Rossano JW; Wilmot I; et al Evaluation and Management of Chronic Heart Failure in Children and Adolescents With Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circulation, 2024.PMID 38808502

[2]Baran DA; Grines CL; Bailey S; et al SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society for Cardiovascular Angiography and Interventions (SCAI), and the Society of Thoracic Surgeons (STS). Catheter Cardiovasc Interv, 2019.PMID 31104355

[3]Fraser CD Jr; Jaquiss RD; Rosenthal DN; et al Prospective trial of a pediatric ventricular assist device. N Engl J Med, 2012.PMID 22873533

[4]Fraser CD Jr; Jaquiss RD The Berlin Heart EXCOR Pediatric ventricular assist device: history, North American experience, and future directions. Ann N Y Acad Sci, 2013.PMID 23750961

[5]Almond CS; Morales DL; Blackstone MH; et al Berlin Heart EXCOR Pediatric ventricular assist device Investigational Device Exemption study: study design and rationale. Am Heart J, 2011.PMID 21884857

[6]Rihal CS; Naidu SS; Givertz MM; et al 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care. J Card Fail, 2015.PMID 26036425

[7]Assmann A; Boekstegers P; Brcic I; et al Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure -A clinical practice guideline. ESC Heart Fail, 2022.PMID 34811959

[8]Bembea MM; Agus M; Akcan-Arikan A; et al Extracorporeal Membrane Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs. Pediatr Crit Care Med, 2023.PMID 36995097

[9]Bhaskar P; Dhar R; Stephenson AL; et al Use of ECMO for Cardiogenic Shock in Pediatric Population. J Clin Med, 2021.PMID 33917910

[10]Sachdev A; Chauhan S; Gupta D; et al Refractory pediatric cardiogenic shock: A case for mechanical support. Indian J Crit Care Med, 2016.PMID 27994387

[11]Schranz D Pharmacological Heart Failure Therapy in Children: Focus on Inotropic Support. Handb Exp Pharmacol, 2020.PMID 31707469

[12]Burkhardt BEA; Rucker G; Stiller B Inotropes for the prevention of low cardiac output syndrome and mortality for paediatric cardiac surgery patients. Cochrane Database Syst Rev, 2024.PMID 39588800

[13]Rossano JW; Cherng An V; Lin KY; et al Heart failure in children: etiology and treatment. J Pediatr, 2014.PMID 24928699

[14]Esangbedo ID; Biagas KV; Ma X; et al Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review. Pediatr Crit Care Med, 2020.PMID 32345933

[15]Feng T; Zhao Y; Li L; et al Clinical outcomes of VA-ECMO in children with fulminant myocarditis: a single-centre case series. BMC Pediatr, 2026.PMID 42056983

[16]Levin A Levosimendan. J Pediatr Intensive Care, 2013.PMID 31214430