Initial Management of Shock
The initial management of shock requires immediate recognition of decreased perfusion, establishing airway and IV/IO access, and administering fluid boluses of 10-20 mL/kg isotonic crystalloid up to 60 mL/kg within the first hour unless hepatomegaly or pulmonary edema develops. 1
Assessment and Recognition
Early recognition of shock is critical for improved outcomes. Signs to assess include:
- Decreased mental status
- Capillary refill >2 seconds (cold shock) or flash capillary refill (warm shock)
- Diminished (cold shock) or bounding (warm shock) peripheral pulses
- Mottled cool extremities (cold shock)
- Decreased urine output (<1 mL/kg/h)
- Abnormal shock index (HR/SBP): >1.2 for ages 1-6, >1.0 for ages 7-12, >0.9 for ages 13-16 2
Immediate Interventions (First 5-15 minutes)
1. Airway and Breathing
- Ensure airway patency
- Provide high-flow oxygen
- Consider early intubation if increased work of breathing, inadequate respiratory effort, or marked hypoxemia 1
- Note: Volume loading is often necessary before intubation as positive pressure ventilation can reduce preload 1
2. Circulation
- Establish vascular access (IV/IO) immediately
- Begin fluid resuscitation:
- Reassess after each bolus for signs of improvement or fluid overload
- Correct hypoglycemia and hypocalcemia 1
3. Medications
- Start antibiotics within the first hour if septic shock is suspected 2
- In neonates, consider prostaglandin until ductal-dependent lesion is ruled out 1
Management of Fluid-Refractory Shock (15-60 minutes)
If shock persists despite adequate fluid resuscitation:
1. Initiate Vasoactive Support
For cold shock (most common in pediatrics):
For warm shock (distributive/septic):
2. Advanced Monitoring
- Consider central venous access and arterial pressure monitoring
- Monitor central venous oxygen saturation (ScvO2) with goal >70%
- Target cardiac index >3.3 and <6.0 L/min/m² 1
Management of Catecholamine-Resistant Shock (>60 minutes)
If shock persists despite vasoactive medications:
1. Consider Adjunctive Therapies
- Administer hydrocortisone if at risk for absolute adrenal insufficiency 1, 2
- Rule out and correct:
- Pericardial effusion
- Pneumothorax
- Ongoing blood loss
- Intra-abdominal hypertension (pressure >12 mmHg) 1
2. Advanced Hemodynamic Monitoring
- Consider pulmonary artery catheter or echocardiography to guide therapy 1
- Adjust therapy based on specific hemodynamic parameters
3. Mechanical Support
- For refractory shock, consider ECMO, particularly in neonates (80% survival rate in neonatal sepsis) 1
- For fluid overload >10% despite diuretics, consider CRRT 1
Therapeutic Endpoints
Target the following parameters:
- Capillary refill ≤2 seconds
- Normal pulses with no differential between peripheral and central
- Warm extremities
- Urine output >1 mL/kg/h
- Normal mental status
- Normal blood pressure for age
- ScvO2 >70%
- Cardiac index >3.3 L/min/m² 1, 2
Common Pitfalls to Avoid
Delayed recognition: Relying solely on hypotension to identify shock is dangerous as it's often a late finding in pediatric patients 2
Inadequate fluid resuscitation: Failure to administer sufficient fluids early can lead to progression to irreversible shock 1
Inappropriate sedation for intubation: Avoid propofol, thiopental, benzodiazepines, and inhalational agents which can worsen hypotension. Ketamine with atropine premedication is preferred for sedation and intubation in shock 1
Etomidate use: Even one dose used for intubation is independently associated with increased mortality in septic shock due to inhibition of adrenal corticosteroid biosynthesis 1
Failure to identify specific causes: Unrecognized morbidities like pericardial effusion, pneumothorax, ongoing blood loss, or metabolic derangements must be addressed 1