Paeds · acute-care-resuscitation-and-toxicology
Cardiogenic and obstructive shock
Also known as Paediatric cardiogenic shock · Obstructive shock in children · Cardiac tamponade · Tension pneumothorax · Low cardiac output syndrome · Pump failure shock
Fellowship guide to paediatric cardiogenic and obstructive shock: recognising the low cardiac output state from pump failure versus mechanical obstruction, the distinguishing bedside signs of cardiac tamponade (Beck triad, pulsus paradoxus) and tension pneumothorax, the cautious fluid and inotrope strategy for cardiogenic shock, the emergency needle decompression and pericardiocentesis that reverse obstructive shock, and the ANZ, AHA and European guideline differences.
Checked against its sources on 3 Sept 2026
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Red flags
- A child with shock and clear lungs, a gallop rhythm, hepatomegaly and cold peripheries has cardiogenic shock until proven otherwise — fluids will harm, so give cautious small-volume crystalloid aliquots with reassessment (not the 10 to 20 mL per kg boluses used in hypovolaemic or distributive shock) and start an inotrope early
- A shocked child with muffled heart sounds, distended neck veins and a narrow pulse pressure is in cardiac tamponade — this is a clinical diagnosis; call for echo-guided pericardiocentesis immediately and do not wait for a chest X-ray
- Sudden hypotension with unilateral absent breath sounds, tracheal deviation away from the affected side and distended neck veins is tension pneumothorax — decompress immediately with needle thoracostomy or finger thoracostomy, do not wait for imaging
- Pulsus paradoxus of more than 10 mmHg in a child with a pericardial effusion signals impending tamponade and cardiovascular collapse
- Sinus tachycardia above 220 per minute in an infant or 180 per minute in a child with signs of poor perfusion is probably a pathological tachyarrhythmia causing cardiogenic shock — apply the 12-lead ECG and cardiovert with a synchronized shock at 1 J per kg, escalating to 2 J per kg
Life stages
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Clinical exam formats
Board mappings
- Acute and critical care
- Recognition and management of the acutely unwell child
- Paediatric emergencies including shock
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Acute and critical care
- Management of cardiogenic and obstructive shock
- Physiology of shock and perfusion
- Clinical Applications
- Acute paediatrics and resuscitation
- Recognition and emergency management of tamponade and tension pneumothorax
- Short Cases
- Critical care and resuscitation scenarios
- Recognition of the low cardiac output state
- 6. Acute and emergency care
- Level 2: Manages shock and the deteriorating child
- Patient management in critical illness
- Applied Knowledge in Practice (AKP)
- Classification of shock and fluid responsiveness
- Cardiac tamponade and tension pneumothorax
- Clinical
- History and management planning
- Simulation of obstructive and cardiogenic shock
- General Pediatrics Content Outline — Domain 2: Emergency Medicine
- General Pediatrics Content Outline — Domain 16: Critical Care
- General Pediatrics EPA: Recognise and stabilise the shocked child
- Patient Care 5: Emergency and acute care
- Patient Care 4: Clinical Reasoning
- Systems-Based Practice: critical-care teamwork and escalation
- Medical Knowledge 1: Clinical Knowledge — shock physiology
- Medical Expert
- Collaborator
- Pediatrics: Core EPA — Recognise and stabilise the shocked child
Overview & Definition
Shock is the failure of the cardiovascular system to deliver enough oxygen to the tissues to meet metabolic demand. It is not defined by a blood pressure reading — a child can be in shock with a normal blood pressure, because compensatory tachycardia and vasoconstriction keep the pressure up until late, and hypotension is a late and ominous sign.[1][17] Shock becomes decompensated when the blood pressure falls below the Pediatric Advanced Life Support hypotension thresholds for age — below 70 mmHg in infants, below 70 + (2 × age in years) mmHg from 1 to 10 years, and below 90 mmHg at 10 years and older.[17]
Paediatric shock is classified by its mechanism into four types: hypovolaemic (loss of volume), distributive (vasodilation, as in sepsis or anaphylaxis), cardiogenic (pump failure), and obstructive (mechanical obstruction to forward flow). This page owns the last two types. Cardiogenic shock is the failure of the heart to generate an adequate cardiac output because of impaired contractility, a structural lesion, or a pathological rhythm. Obstructive shock is the failure of forward flow because something mechanical is blocking the heart or the great vessels: cardiac tamponade, tension pneumothorax, or massive pulmonary embolism.[1][3]
The reason cardiogenic and obstructive shock are grouped together is that they share a cold, low-output phenotype and, crucially, they are the two shock types where aggressive fluid resuscitation can harm. Both demand early vasoactive support or physical decompression rather than the large-volume crystalloid boluses that rescue hypovolaemic and septic shock. Recognising the type within the first minutes of assessment is the skill that separates the safe from the dangerous resuscitation.[1]
References17ShowHide
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- [2]Mendelson J Emergency Department Management of Pediatric Shock. Emerg Med Clin North Am, 2018.PMID 29622332
- [3]Morgan WM 3rd, O'Neill JA Jr Hemorrhagic and obstructive shock in pediatric patients. New Horiz, 1998.PMID 9654322
- [4]Law YM, Lal AK, Chen S, et al. Diagnosis and Management of Myocarditis in Children: A Scientific Statement From the American Heart Association. Circulation, 2021.PMID 34229446
- [5]Schmidt M, Burrell A, Roberts L, et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J, 2015.PMID 26033984
- [6]Ahmad SJS, Degiannis JR, Head M, et al. Meta-analysis of the optimal needle length and decompression site for tension pneumothorax and consensus recommendations on current ATLS and ETC guidelines. World J Emerg Surg, 2025.PMID 40383767
- [7]Harris M, Rocker J Pneumothorax In Pediatric Patients: Management Strategies To Improve Patient Outcomes. Pediatr Emerg Med Pract, 2017.PMID 28252382
- [8]Fields JT, O'Halloran CP, Tannous P, et al. Differences in outcomes between surgical pericardial window and pericardiocentesis in children with postpericardiotomy syndrome. Ann Pediatr Cardiol, 2023.PMID 38817257
- [9]Donovan M, Smith N, Holton R, et al. Pediatric Bacterial Pericarditis. Am J Emerg Med, 2020.PMID 31859192
- [10]Alerhand S, Choi A, Varga P Cardiac Ultrasound for Pediatric Emergencies. Pediatr Ann, 2021.PMID 34617847
- [11]Alsabri M, Abo-Elnour DE, Ayyad M, et al. Epidemiology and management of massive, sub-massive, and non-massive pediatric pulmonary embolism: a systematic reviews. BMC Pediatr, 2025.PMID 40287637
- [12]Ji D, Gill AE, Durrence WW, et al. Catheter-Directed Pharmacologic Thrombolysis for Acute Submassive and Massive Pulmonary Emboli in Children and Adolescents-An Exploratory Report. Pediatr Crit Care Med, 2020.PMID 31688811
- [13]Khalil M, Jux C, Rueblinger L, et al. Acute therapy of newborns with critical congenital heart disease. Transl Pediatr, 2019.PMID 31161078
- [14]Zaidi AU, Hutchins KK, Rajpurkar M Pulmonary Embolism in Children. Front Pediatr, 2017.PMID 28848725
- [15]Schneider H Management of arterial hypotension in critically Ill children: a narrative review and practical approach. Front Pediatr, 2026.PMID 42305569
- [16]Shanker DA, Gaur A, Warriner D Pericardial Effusion: Overview of Aetiology, Pathophysiology, Diagnosis, and Management. Cureus, 2025.PMID 41084698
- [17]Singer CE, Pluta ID, Vintilescu SB, et al. Pediatric Shock Across Acute Emergencies: Age Patterns, Etiologic Subtypes, and Bedside Clinical Indicators in a Single-Centre Cohort. Children (Basel), 2026.PMID 41897079