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Shock

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Shock is a state of abnormal circulation where the O2 and nutrient needs of tissues are not being met. Shock affects all organ systems independently of the cause. The clinical signs of shock in any individual child are the result of a combination of many complex body responses.

Shock may occur as the result of hypovolaemia (fluid loss or redistribution within the body) or cardiac dysfunction. Hypovolaemic shock is most common in children due to such causes as trauma, gastrointestinal losses, or redistribution in sepsis.

Well established shock is easy to recognise but difficult to manage with many poor outcomes due to irreversible organ damage. If the subtle early signs of shock are detected and managed appropriately, these bad outcomes can be avoided.

Recognition

Early recognition of shock requires a clear understanding of normal children's behaviour and appearance under a variety of circumstances. Subtle pallor, cool peripheries, slight drowsiness or disinterest in surroundings, and tachycardia disproportionate to other factors such as anxiety or fever are all important and often overlooked.

Reduced urine output is another important sign, children with severe trauma or sepsis require urinary catheters to allow accurate recording and fluid management.

Normal values for pulse and blood pressure at different ages are tabulated in this manual. Be aware however that "normal" values are sometimes not an appropriate guide when children are distressed. By the time that there is a detectable fall in blood pressure, the child will be severely symptomatic and obviously shocked on a global assessment; do not rely on a normal BP to exclude shock.

"Capillary return" is a traditional sign that is based on minimal evidence of what constitutes normal. A capillary return of > 2 seconds will be found in many small children at normal room temperatures.

Frequent recording of GCS, pulse, blood pressure, respiratory rate and general appearance allow a child's condition to be tracked over time - shock is a progressive condition. As in most paediatric clinical assessment it is the synthesis of all observed information that is critical rather than focusing on a few limited measurements. While a single assessment of pulse rate is relatively uninformative, checking the trend over several hours in a child admitted with unexplained fever may give a valuable early warning.

Early Management

Children in CED with signs of shock should be managed in the receiving room. Other children already admitted to hospital should have fluid resuscitation initiated and be rapidly transferred to PICU. If requiring aggressive resuscitation, a "777" call out should be requested.

  • Management should follow the standard ABC approach, with tasks allocated according to the Emergency Team guidelines. All cases should receive at least high flow face mask O2, even if breathing adequately, & regardless of oxygen saturation level.
  • In known or suspected trauma, the cervical spine must be immobilised during airway management and obvious bleeding controlled with pressure.
  • Commence monitoring of heart rate/rhythm, respiratory rate, pulse oximetry and blood pressure immediately.
  • Intravascular fluid volume expansion is the next priority as soon as access is obtained. Ideally more than one IV cannula should be placed (as large as possible). The fluid will need to be set up to allow rapid infusion. For small infants a 3 way tap and syringe is an efficient way to infuse fluid rapidly through a narrow cannula. For older children, infusion sets with hand pumps built into the line are ideal.
  • Vascular access may be difficult. In this situation even a 24G needle in a small peripheral vein can allow a significant volume of fluid to be pushed through using a syringe and 3 way tap. Intraosseus needles are very useful and can be used in conscious children with local anaesthetic infiltration. A variety of lines can be inserted into the femoral vein using Seldinger techniques. Venous cut down is difficult and time consuming but provides excellent access when achieved (this can be undertaken if necessary while other techniques are in progress).
  • The initial fluid bolus should be Normal Saline 20ml/kg; given as rapidly as possible. Preferably this should pass through a rapid fluid warmer. Further boluses of normal saline should be given according to effect, alternatively use a colloid solution such as Haemaccel or albumin can be used for subsequent boluses.
  • Fresh frozen plasma may be required for clotting disturbance & bleeding.
  • Inotropes - use Dopamine for hypotension refractory to volume replacement or recurrent despite adequate fluids. Dose - initially 5 microgram/kg/min IV increasing stepwise to maximum of 15-20 microgram/kg/min.

Investigation

All Children

Electrolytes, ABG, urea/creatinine, glucose, full blood count, liver function and clotting screen, blood group and hold.

Trauma

See trauma manual. If no visible bleeding then usually due to intra-abdominal injury. Consider spinal injuries in those children with unexplained shock and poor response to therapy.

Other Children

The cause may be fairly obvious on history or examination, for instance with gastroenteritis or meningococcal disease.

In children with unexplained shock consider

  • Bacterial Sepsis:
    All should have a full work up and antibiotic cover pending culture results. Lumbar puncture should be deferred until the child is haemodynamically stable.
  • Intrabdominal Problems:
    Intussusception
    Volvulus
    Other peritoneal/intraluminal "3rd spacing".
  • Undisclosed or Non-Accidental Injury:
    Duodenal hematoma
  • Poisoning:
    Hypoglycaemia
    Dysrhythmias
    Vasodilation
  • Primary Cardiac Causes:
    Investigation should be targeted according to history and presentation and include specific tests such as abdominal ultrasound or cardiac echo in some cases.

Subsequent Management

  • Uncontrolled bleeding may require transfer from CED directly to theatre. However if the child is haemodynamically stable after fluid resuscitation then CT is indicated to determine the source of bleeding. The great majority of children with intra-abdominal haemorrhage are managed conservatively. Children should not be moved from the receiving room with ongoing signs of uncontrolled shock unless going to theatre or PICU with continuing resuscitation en route.
  • Following any episode of uncompensated shock, children should be admitted to PICU. Children whose signs are detected and managed early may be able to be admitted to the ward provided that they are observed sufficiently in CED to ensure that they are stable, and they have been discussed with the consultant on duty.

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Document Control

  • Date last published: 01 July 2005
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Author(s): Richard Aickin
  • Editor: Greg Williams
  • Review frequency: 2 years

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