Shock: Recognition
- There is no single pathognomonic finding that defines shock.
- Hypotension is a late finding, but an ominous one, in kids.
- Constellation of findings:
- Tachycardia
- Tachypnea
- Poor perfusion
- Poor pulse quality
- Altered mental status
- Cold Shock findings:
- High Systemic Vascular Resistance
- Cold, clammy, mottled, or cyanotic extremities
- Capillary Refill > 2 seconds
- Diminished / thready pulses
- Narrow pulse pressure.
- Respect the “just ain’t right” findings:
- Poor feeding
- Jittery
- Irritable
- Lethargic
- Once recognized, be aggressive within 1st hour!
- IV or IO 40-60 ml/kg of isotonic fluids PUSHED rapidly
- Do not hang to gravity or on a “pump.”
- Use syringe pushes or pressure bags
- Children commonly will require 40-60 ml/kg in the 1st hour, but may require more (some say 200 ml/kg in 1st hour in right clinical setting).
- Don’t forget about Glucose!
- Optimize oxygenation
- Supplemental may be all that is initially needed.
- 30-40% of a child’s cardiac output goes to the work of breathing when critically ill, so often will require additional support (i.e., intubation).
- Broad spectrum antibiotics
- Keep your Differential open!
- While ordering empiric antibiotics, consider the other causes of SHOCK in children.
- The child with fluid-refractory shock deserves a second and third consideration for the other possible culprits!
- Use your bedside Ultrasound
- Pericardial Effusion & Tamponade?
- Overview of heart function / squeeze / size
- IVC volume? – perhaps more fluids aren’t the answer
- Pneumothorax?
- Free intra-abdominal fluid? – Is there occult trauma??
- Do not hesitate to start vasopressors.
- Children with fluid-refractory shock tend to respond to inotropes.
- Reversing shock is associated with better survival.
- Common perception is that vasoactive medications (vasopressors) need to be give via central line.
- In an ideal setting, this is reasonable. That 1st hour of critical illness is often not ideal.
- There is no data clarifying whether one vasopressor is more harmful when given peripherally than another.
- Epinephrine has been shown to be safe and effective when given via peripheral IV or IO in the setting of Septic Shock. [Ramaswamy, 2016; Ventura, 2015]
- Time is critical; central lines aren’t easy in children; PIVs and IOs work just fine!