Cardiogenic shock and mechanical circulatory support

The single idea that organises the topic is this: in cardiogenic shock the problem is the pump, so the answer is to support the pump while you find and fix the cause, and the device is what you reach for when drugs cannot. A child with fulminant myocarditis can arrest within hours of looking mildly unwell, and the intervention that reverses the course is not more fluid or a bigger inotrope dose — it is a machine that takes over the pumping. The discipline that saves these children is early recognition of the perfusion failure, restraint with fluid, and timely escalation to a centre that can deploy mechanical support. [9] [10]

This page covers the bedside distinction of cardiogenic shock from the other shock types, the pathophysiology that explains why the child spirals, the cautious-fluid and inotrope resuscitation, the SCAI shock stages, the escalation to extracorporeal membrane oxygenation and a ventricular assist device, and the anticoagulation and complication burden of the devices. It links to the myocarditis leaf for the commonest reversible trigger, the cardiomyopathies leaf for the durable-support substrate, and the duct-dependent congenital heart disease leaf for the neonatal prostaglandin rescue. [13] [1]

Overview & Definition

Cardiogenic shock is inadequate tissue perfusion caused by failure of the heart as a pump. The cardiac output falls, and because the ventricle cannot eject its filling volume, the pressures behind the heart rise. The child therefore shows two things at once: the forward signs of low flow (cold peripheries, weak pulses, a long capillary refill, oliguria and a rising lactate) and the backward signs of congestion (a raised jugular venous pressure, hepatomegaly, pulmonary oedema and a gallop rhythm). That combination — low output with congestion — is the bedside signature that separates cardiogenic shock from the other shock types. [2] [13]

The contrast matters because it changes the first action. In septic shock the child is often warm and the first move is to push in fluid. In cardiogenic shock the ventricle is failing, so pushing in fluid floods the lungs and the liver. The general paediatrician's job at the bedside is to spot the congestion, hold back on aggressive fluid, start an inotrope, and escalate the child who does not respond. [12] [11]

Mechanical circulatory support is the family of devices that take over the pumping function of the failing heart. They range from temporary devices that run for hours to weeks — venoarterial extracorporeal membrane oxygenation is the commonest — to durable ventricular assist devices that run for months to years while a child waits for transplant. Every device serves one of four goals: bridge to recovery, bridge to transplant, bridge to candidacy, or destination therapy. Fulminant myocarditis is the classic bridge to recovery; cardiomyopathy is the classic bridge to transplant. [6] [4]

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