This document provides guidelines for the management of shock in children. It defines shock as a pathophysiological state characterized by inadequate tissue perfusion. The main types of shock are hypovolemic, distributive, cardiogenic, and obstructive. Initial evaluation of a child in shock involves assessing appearance, breathing, and circulation to identify life-threatening conditions and classify shock severity and type. Management begins with oxygen, IV access, glucose check, and fluid boluses. Further treatment depends on shock type but may include antibiotics for sepsis, vasoactive drugs for cardiogenic shock, or epinephrine for anaphylaxis. Children are monitored for response and complications, with transfer to ICU for non-responders.

1. MANAGEMENT OF SHOCK IN
CHILDREN
Resident (pediatrics department)
Dr. Madan kr Timalsena
KISTMCTH

2. OBJECTIVES
 Define shock
 Explain pathophysiology in short
 Explain clinical and severity classification of shock
 Explain initial evaluation of shock
 Explain initial management of shock
 Explain management of shock

3. WHAT IS SHOCK ?
 Shock is a dynamic and unstable pathophysiologic
state
 Characterized by inadequate tissue perfusion
 If not treated promptly leads to invariable
progression and poor outcome leading to end organ
damage , failure of multiple organ systems and
mortality

4. PATHOPHYSIOLOGY OF SHOCK:
 Can develop from variety of conditions:
• decreased intravascular volume(hypovolemic shock)
• abnormal distribution of intravascular volume(distributive shock)
• impaired cardiovascular function(cardiogenic shock)
• obstruction to cardiac outflow(obstructive shock)
 All of which leads to decreased tissue perfusion causing:
• Inadequate blood supply to vital organs
• Lactic acidosis due to anaerobic metabolism
• Release of inflammatory mediators
• Release of stress hormones causing glycolysis and lipolysis

5. CLINICAL CLASSIFICATION AND USEFUL FINDINGS
 Hypovolemic shock
 History of volume loss or hemorrrhage
 Narrow pulse pressure
 Signs of poor peripheral perfusion
 Small/normal sized heart in chest radiograph
 Distributive shock(vascular dialation typically cause
widened pulse pressure)
specific features associated with types:
• Septic shock: fever , immunocompromised state , purpuric rash ,
abnormal white blood cell , DIC
• Anaphylactic shock: history of exposure to allergens , stridor ,
wheeze , vasodialation , urticaria ,facial edema
• Neurogenic shock:history of trauma with severe head or cervical
spine injury ,hypotension ,bradycardia

6.  Cardiogenic shock :
 history of congenital heart disease
 Palpitation
 signs of heart faliure(rales,hepatomegaly,gallop rhythm
,distended jugular vein)
 arrhythmia
 Obstructive shock
 History of thoracic trauma , Deviation of trachea
 Muffled heart sound , Pulsus paradoxus
 Abrupt circulatory collapse in PE (history of
thrombophilia or sickle cell disease)
 Abrupt onset murmur , shock or cyanosis in duct
dependent CHD (crirical coarctaction of aorta, hypoplastic
lt heart) with in 1st few weeks of life due to closure of
ductus arteriosus

7. EPIDEMIOLOGY OF SHOCK IN CHILDREN:
 Most common type of shock in children is
hypovolemic
 Most common cause is diarrheal disease
 Sepsis is another common cause of shock especially
in LBW newborn, younger children, and
immunosupressed children
 Cardiogenic and obstructive shock are less common
in children but must be considered as they are
typically not fluid responsive and requires specific
therapies

8. INITIAL EVALUATION OF SHOCK:
 Goals of initial evaluation:
• Immediate identification of life threatening condition(eg
tension pneumothorax,hemothorax,cardiac
tamponade,pulmonary embolism)
• Rapid recognization of circulatory compromise
• Early classification of type and cause of shock for early
effective treatment

9.  Helps in identifying a child with respiratory and
circulatory compromise or both who require
immediate supportive care and prompt evaluation

10. APPEARANCE:
 Poor tone , unfocused gaze,weak cry may be indicators of
decreased cerebral perfusion
 Subtle difference in appearance like decreased responsive to care
takers or decrease response to painful procedure may be an
important indicator of shock
 A child with depressed mental status as a result of shock may not
ne able to maintain airway
 Other added sounds like stridor ,wheeze(anaphylaxis)crackles
(pneumonia,septic shock) or decreased breath
sound(pneumothorax) give important information towards the
cause of shock
BREATHING:

11. CIRCULATION:
Poor perfusion can often be identified before BP measurement
• Decreased intensity of peripheral pulse in comparison to
central pulses suggests peripheral vasoconstriction and
compensated shock
• Bounding pulse may be present in distributive shock
• Skin temperature may be cold in children with compensated
shock while warm temperature suggests peripheral
vasodialation thus distributive shock
• Capillary refill >2 seconds suggests shock but flash capillary
refill <1 second may be seen in distributive shock
• Tachycardia is frequent and early sign but bradycardia in
spinal shock should always be kept in consideration

12. • Tension pneumothorax: difficulty in breathing,
decreased breath sound over hemithorax ,tracheal
deviation,surgical emphysema,distended neck veins are
seen where immediate needle decompression(2nd
intercostal space in mid clavicular line) is required
• Cardiac tamponade: respiratory distress,muffled heart
tones,pulsus paradoxus are seen where
pericardiocentesis is emergently required.
Other such conditions are duct dependent CHD,
pulmonary embolism.
CHILDREN WITH SEVERE RESPIRATORY DISTRESS AND SIGNS OF
CIRCULATORY COMPROMISE IN INITIAL ASSESSMENT MAY HAVE
OBSTRUCTIVE SHOCK REQUIRING IMMEDIATE LIFE SAVING
INTERVENTION BEFORE FURTHER EVALUATION IS INITIATED:

13. HISTORY: IMPORTANT POINTS TO CONSIDER
 History of fluid loss (AGE,DKA,GI bleed) is consistent with
hypovolemic shock
 Injured children may have hypovolemic shock from hemorrhage or
obstructive shock (pneumothorax , cardiac tamponade) or spinal
shock(neurogenic)
 Fever /immunocompromised state may indicate septic shock
 History of exposure to allergens (insect bites,sea foods) suggests
anaphylactic shock
 Patients with chronic heart disease(cardiomyopathy,CHD) may
develop cardiogenic shock
 Adrenal crisis in suceptible patients should be considered(chronic
steroid therapy, congenital adrenal insufficiency or sepsis)

14. PHYSICAL EXAMINATION:COMPLETE PHYSICAL
EXAMINATION WITH VITALS AND OXYGEN SATURATION
Vital signs provide essential information regarding
cause,classification and severity of shock:
• Respi rate: usally tachypneic . In capnography raised etco2 in response
to metabolic acidosis is seen. Low etco2 is an ominous finding due to
decrease pulmonary perfusion in shock.
• Heart rate: tachycardia is consistent and early sign(except for
cardiogenic shock from bradyarrhythmia or spinal shock)
• Blood pressure: children with shock may have normal BP however but
hypotension if present should be rapidly identified as it rapidly
progress to cardiovascular collapse and arrest
• Tempr : fever(or hypothermia in young infants) is often consistent
with septic shock

15.  Pulse pressure:
• Narrow pulse pressure
 typically <30mm of hg in older child
 occurs when diastolic blood pressure is increased as the result of
compensatory increase in systemic vascular resistance
 eg with hypovolemic and cardiogenic shock
• Widening of pulse pressure
 typically>40mmof hg in older children
 seen in distributive shock as a result of decreased vascular
resistance
 low pulse pressure may reflect widening of pulse in young
infants

16. ADDITIONAL FEATURES OF PHYSICAL EXAMINATION
 Stridor or wheeze is heard in anaphylaxis
 Crackles may be heard in heart faliure (cardiogenic shock) or pneumonia(septic shock)
 Asymmetric breath sound may suggest toward tension pneumothorax(obstructive shock)
 Distended neck veins suggests an abnormality of cardiac contractility or obstruction to venous
return(tamponade,pneumothorax or hemothorax)
 Pulse differntial in upper and lower limb suggests aortic coarctation
 Hepatomegaly due to hepatic congestion can be seen in heart faliure
 Abdominal distension,masses or tenderness is consistent with bowel obstruction,perforation or
peritonitis
 Abnormal skin findings like urticaria or facial edema suggests anaphylaxis
 Purpura can be seen in septic shock

17. APPROACH TO UNDIFFERENTIATED SHOCK

18. INVESTIGATIONS: USEFUL FOR SUCCESSFULLY TREATING SHOCK,IDENTIFYING
ETIOLOGY,AND MONITORING RESPONSE TO TREATMENT
BUT SHOULD BE OBTAINED SIMULTANEOUSLY WITH ASSESSMENT AND TREATMENT
 Hypovolemic shock without hemorrhage
• Rapid glucose
• Serum electrolytes
• Blood lactate (marker of tissue perfusion and metabolic stress)
• Urine dipstick (specific gravity, glycosuria or ketonuria)
• Chest x ray(who donot improve after 60ml/kg of fluid to rule out
other cause ,to see cardiomegaly to taper fluid therapy)
• Abdominal x ray(to rule out third spacing)
o Hypovolemic shock with hemorhage
• Hematocrit
• ABG
• Blood type and cross match
• Coagulation studies(pt/inr ,aPTT)
• Chest radiograph
• Abdominal radiograph/FAST scan if possible

19.  Septic shock
 Rapid glucose
 ABG
 Complete and differential blood count
 Serum lactate
 Serum electrolytes
 Blood urea nitrogen and serum creatinine
 Ionized blood calcium
 Total bilirubin and alanine amino transferase
 PT/INR,aPTT(to rule out DIC)
 Fibrinogen and d-dimer
 Blood culture
 Urine analysis/culture
 Inflammatory biomarkers like(CRP,ESR,procalcitonin)

20.  Cardiogenic shock
 12 lead ECG(mainstay) along with cardiac biomarkers to rule out
arrhythmias
 Used in conjunction with clinical features and investigations to
rule out other causes of shock as suspected
 Obstructive shock
 Chest x ray can be diagnostic for tension pneumothorax and
hemothorax
 But whenever possible should be diagnosed clinically and
urgently treated
 Ct chest in pulmonary embolism should be done only after initial
stabalization(o2 support,fluid resuscitation,vasopressor support)
 Bedside transthorac or transesophageal echo can be useful in
unstable patients to establish presumptive diagnosis and justify
the use of thrombolytic therapy

21. INITIAL MANAGEMENT OF SHOCK
 Targets of initial management of shock
 Strong distal pulse(equal to central pulse)
 Skin warm with capillary refill<2sec
 Normal mental status
 Systolic pressure >5th percentile for age
 Urine output >1ml/kg/hr
With in 5-15 min of recognition following action should be
commenced:
• Give oxygen
• Monitor HR, oxygen saturation continiously and BP frequently
• Establish IV or IO access (preferably IV 22 -24 gauge for newborn
and 18-20 gauge for children)
• Obtain blood glucose and treat hypoglycemia
• Identify life threatening obstructive cause of shock

22.  In children without sign of fluid overload,isotonic crystalloid
infusion(ringers lactate or normal saline) should be started
 Rapid infusion of 20ml/kg over five min should be performed in
children who are hypotensive without findings of cardiogenic
shock
 Patients with compensated shock should also receive 10-20
ml/kg over 5-20 min as long as there are no signs of
cardiogenic or obstructive shock
 For children with signs of cardiogenic shock who may bw
hypovolemic fluid should be given cautiously (eg 5 to 10ml/kg
over 15-30mins)
 Children with anaphylaxis should receive im epinephrine
,diphenhydramine and glucocorticoid
 Other diagnostic studies should be obtained as indicated
according to type of shock
 After initial bolus target physiological indicators should be
evaluated

23. Over the next 15 to 60 min following action are warrented:
o Abnormalities in calcium and electrolyte measurement should be
identified and treatment initiated
o Appropriate antibiotic therapy should be started for septic shock
o Children other than with obstructive and cardiogenic shock who
have not improved with initial fluid bolus should continue to
receive fluid boluses in 20ml/kg to a total of 60ml/kg over first
60 min of treatment
o Vasoactive drug therapy may be initiated in children with
possible cardiogenic or neurogenic shock who have not
responded to fluid
o Vasoactive agents should also be considered in septic shock who
have not responded to 60ml/kg or more of fluid boluses
o Children who have not improved over 60 min of initial treatment
should be reevaluated for other causes of shock

24.  Commonly used drug and dosing:
 Epinephrine:
 for asystole or pulseless arrest (1:10000) iv or io at 0.1ml/kg every 3-5
min till return of spontaneous circulation
Endotracheal (1:1000) at 0.1 ml/kg
• FOR iv INFUSION : 0.05 TO 1 MCG/KG/MIN
• ANAPHYLAXIS (1:1000) AT 0.01ML/KG/DOSE
• NOR-EPINEPHRINE:
• INITIALLY AT 0.05 T0 0.1 MCG/KG/MIN TIRATED AT MAXIMUM
DOSE 2MCG/KG/MIN
• DOPAMINE:
 STARTED AT 2-20 MCG/KG/MIN WITH GRADUAL 5-10 MCG/KG/MIN
UNTIL OPTIMAL RESPONSE
 DOBUTAMINE IN CARDIOGENIC SHOCK:
 INITIAL DOE 0.5-5MCG/KG/MIN IS TITRATED TO BP AND
ENDORGAN PERFUSION TO MAXIMUM DOSE OF 20-40MCG/KG/MIN

25. CATECHOLAMINE RESISTANT SHOCK:
 Failure to maintain MAP above 65mmof hg or higher
despite 6 hrs of vasopressor
 Treated with hydrocortisone 50mg/kg /day
 Patient not improving after hydrocortisone should be
considered for ECMO

26. DISPOSITION:
 Children whose shock resolve with treatment should
be admitted for observation
 The cause of shock may persist and reoccur(eg
diarrhoea)
 Children who do not improve should be admitted to
ICU
 Patient with hemorrhagic shock should be evaluated
by trauma surgeon
 Failure to recognize nonn specific signs of
compensated shock ( eg tachycardia,poor skin
perfusion)
PITFALLS:

27.  Inadequate monitoring
 Inappropriate fluid resuscitation(too little for
hypovolemic shock or too much for cardiogenic and
obstructive shock)
 Failure to reconsider other cause of shock in patients
who are not improving
 Failure to recognize and obtructive shock due to life
threatning condition
 Failure to consider multiple type of shock in single
patient

28. THANK YOU!