Pre-PICU Prep - Dr. Sean Fox

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:
  

1. Tachycardia
2. Tachypnea
3. Poor perfusion
4. Poor pulse quality
5. Altered mental status
   

• Cold Shock findings:

1. High Systemic Vascular Resistance
2. Cold, clammy, mottled, or cyanotic extremities
3. Capillary Refill > 2 seconds
4. Diminished / thready pulses
5. Narrow pulse pressure.

• Respect the “just ain’t right” findings:

1. Poor feeding
2. Jittery
3. Irritable
4. Lethargic 

Be Aggressive Early

• Once recognized, be aggressive within 1st hour!
• IV or IO 40-60 ml/kg of isotonic fluids PUSHED rapidly

1. Do not hang to gravity or on a “pump.”
2. Use syringe pushes or pressure bags
3. 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

1. Supplemental may be all that is initially needed.
2. 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

Fluid-Refractory Shock

• 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

1. Pericardial Effusion & Tamponade?
2. Overview of heart function / squeeze / size
3. IVC volume? – perhaps more fluids aren’t the answer
4. Pneumothorax?
5. Free intra-abdominal fluid? – Is there occult trauma??

Vasopressors can be Started Peripherally

• 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! 

 

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