Cardiogenic shock and mechanical circulatory support — structured clinical encounter

Encounter structure

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

1. 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]

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]

3. 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]

4. 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]