The initial signs of shock may be subtle in children and infants as their compensatory mechanisms are very effective.  As long as the compensatory mechanisms are able to maintain a systolic BP within an age-appropriate normal range, the shock is considered compensated.  When the compensatory mechanisms fail, the child progresses quickly to decompensated shock where the “classic” signs and symptoms of shock are present, such as tachycardia, pallor, cold extremities, and altered levels of consciousness.  When this happens, cardiopulmonary arrest may be imminent.

Children are capable of compensation for long periods of time after which they quickly decompensate.  Recovery from decompensated shock is less likely.  Caution must be always used when assessing children with special needs or chronic health conditions as they are more difficult to assess for what is “normal.”

• Know and be familiar with normal vital signs for given ages.  Use a reference tool (either app or pocket card) before patient contact.  Do not rely on memory.
• Assess patients early and from a distance
• Early recognition and intervention are the keys to survival
• Treatments must be targeted to the underlying cause.  Vascular access is critical, but not all problems are responsive to fluid. 
• Maintain normal oxygen saturation
• Classic systems-based shock categories are septic, hypovolemic, anaphylactic, cardiogenic, obstructive, and spinal

• In addition to oxygen, vascular access and patient positioning, type-specific priorities are:
  • Septic shock: 10-20 mL/kg crystalloid bolus, early antibiotics, pressors, steroids, and blood products
  • Anaphylactic shock: EPINEPHrine 0.01 mg/kg, 10 mL/kg crystalloid bolus (repeated as necessary), vasopressors, and steroids
  • Hypovolemic: 20 mL/kg crystalloid bolus, packed red blood cells, platelets, and plasma
  • Cardiogenic: 5-10 mL/kg crystalloid bolus (Clinicall/TA consult), arterial line monitoring, pressors, inotropes, and chronotropes
  • Obstructive: Identify and treat cause
  • Spinal: 10 mL/kg fluid bolus (may repeat as necessary), pressors, and inotropes

All patients demonstrating signs and symptoms of shock require rapid transport to the most appropriate hospital depending on resources.

• The recognition of shock relies on careful assessment of the child while at rest.  Stimulation – from handling, blood work, vital sign measurements – may agitate the child producing tachycardia, tachypnea, and color changes.
• The initial assessment should follow the pediatric assessment triangle:
  • Appearance: Restlessness or inconsolability, decreased interactivity, decreased motor activity, lethargy and listlessness, decreased consciousness, weak cry, and poor eye contact
  • Respiratory: Increased work of breathing, primarily tachypnea
  • Circulation: Poor skin perfusion, cool periphery, delayed capillary refill, pallor, tachycardia, and weak pulses
• Further assessment will reveal objective findings.  These should be broken down into systems:
  • CNS: GCS less than 15, hypotonia or hyporeflexia, seizures (late and ominous)
  • Cardiovascular: tachycardia (early) or bradycardia (late and ominous), weak or absent pulses (may be bounding in cardiogenic or “warm” septic shock), ECG changes, elevated lactate, metabolic acidosis, absent or muffled heart sounds
  • Respiratory: tachypnea, accessory muscle use, hypoxemia, pneumothorax
  • GI/GU: decreased or concentrated urine output, flank pain, incontinence (spinal shock)
  • Integumentary: reduced turgor, rash, mottling, delayed capillary refill

Hypovolemic Shock

Pediatric Anaphylaxis

Septic Shock