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determine if hypovolemia is improved. A decrease in the IVC respiratory
variation may indicate that the patient may not respond to further fluid
resuscitation. An IVC/Ao ratio of 1 to 1.4 is indicative of euvolemia, and >1.4
is indicative of hypervolemia. It is important to note that positive pressure
ventilation may distend the IVC and limit the evaluation of fluid status using
the IVC/Ao ratio.
Cardiogenic Shock. Cardiogenic shock is often difficult to distinguish from
other shock states, as a prolonged history of worsening symptoms is less common
in children as compared to adult heart failure. Historical information should be
obtained regarding chest pain, syncope, known cardiac abnormalities, and cardiac
medications. On physical examination, one should assess the following:
Neck: Jugular venous distention
Cardiac: Murmur, gallop, perfusion abnormalities including delayed capillary
refill, diminished or bounding pulses
Respiratory: Respiratory distress, rales to suggest pulmonary edema
Abdomen: Hepatomegaly
Extremities: Peripheral edema, delayed capillary refill
POCUS findings: Distended IVC, right and/or left ventricular or biventricular
dysfunction, possible ventricular dilation, pulmonary edema may be seen on
lung ultrasound.
Obstructive Shock. On physical examination, one should assess the following:
Neck: Jugular venous distention
Cardiac: Murmur, gallop
Respiratory: Unilateral decreased breath sounds suspicious for tension
pneumothorax
Abdomen: Hepatomegaly
Extremities/skin: Poor perfusion, cyanosis in unrepaired congenital heart
disease including differential perfusion, and cyanosis between the upper and
lower extremities to indicate interrupted aortic arch or critical aortic coarctation
Beck triad in cardiac tamponade: Distended neck veins, hypotension,
diminished heart sounds

POCUS findings: Distended IVC, possible right ventricular dilation and systolic
dysfunction in pulmonary embolism or tension pneumothorax, possible
pericardial effusion in cardiac tamponade.