Clinical Scenario:
An 18-month-old boy presents with 5 days of poor feeding and cough, worsening over the last 12 hours. He is lethargic, HR 190/min, RR 68/min with retractions, CRT 4 sec, weak pulses, and BP 68/40 mmHg. Gallop rhythm and bilateral crepitations are heard, liver is enlarged. CXR shows cardiomegaly with pulmonary congestion. Echo confirms dilated LV with EF 20%, no structural defect. A cautious 5 mL/kg saline bolus is given; the child remains hypotensive with poor perfusion and no worsening crepitations.
What is the most appropriate next step?
A. Furosemide bolus
B. Milrinone infusion
C. Prostaglandin infusion
D. Repeat saline bolus
E. Synchronized cardioversion
Correct answer & Explanation:
Correct Answer: B — Milrinone infusion
Explanation:
Why B is correct: Fluid-refractory cardiogenic shock requires inotropic/inodilator support. Milrinone improves contractility and reduces afterload, ideal for cardiomyopathy-related shock.
Why others are wrong:
- A — Treats congestion, not hypotension/poor perfusion.
- C — No structural/duct-dependent lesion present.
- D — Risks fluid overload without evidence of ongoing hypovolemia.
- E — Tachycardia here is compensatory, not a primary arrhythmia.
