What is the initial management for a 7-year-old child weighing 33kg presenting with shock?

Initial Management of Shock in a 7-Year-Old Child (33kg)

Immediately establish vascular access (IV or intraosseous if IV cannot be obtained within minutes), begin rapid fluid resuscitation with 20 mL/kg boluses of isotonic crystalloid (660 mL for this 33kg child), and prepare for potential vasopressor support if shock persists after initial fluid therapy. 1, 2

Immediate Assessment and Stabilization

Airway and Breathing:

• Assess for increased work of breathing, altered mental status, and adequacy of oxygenation—intubation should be considered before waiting for confirmatory laboratory tests if these signs are present 1
• Provide high-flow oxygen immediately to all children in shock 2
• Up to 40% of cardiac output is consumed by work of breathing, so early intubation and mechanical ventilation can reverse shock by reducing this metabolic demand 1
• If intubation is required, administer fluid boluses and consider peripheral inotropic support before intubation, as sedation can worsen hypotension in hypovolemic patients 1

Circulation - Vascular Access:

• Establish intraosseous access if reliable venous access cannot be obtained within minutes 1, 2
• Avoid delays—the goal is vascular access within the first few minutes of recognition 1

Fluid Resuscitation Protocol

Initial Fluid Boluses:

• Administer 20 mL/kg (660 mL for this 33kg child) of isotonic crystalloid (0.9% saline or lactated Ringer's) as a rapid push or via pressure bag 1, 2
• Reassess perfusion after each bolus, looking for capillary refill ≤2 seconds, warm extremities, normal pulses, improved mental status, and adequate urine output (>1 mL/kg/hr) 1, 2
• Children commonly require 40-60 mL/kg in the first hour, and up to 200 mL/kg may be necessary in severe cases 1
• There is no benefit to using colloid (albumin) over crystalloid during early resuscitation in pediatric shock 1

Monitoring During Resuscitation:

• Observe for signs of fluid overload: increased work of breathing, rales, gallop rhythm, or hepatomegaly 1
• If these signs develop, stop fluid administration and reassess 1
• Monitor vital signs continuously: heart rate, blood pressure, temperature, pulse oximetry, and urine output 1, 2

Hemodynamic Support for Fluid-Refractory Shock

When to Initiate Vasopressors:

• If shock persists despite 40-60 mL/kg of fluid resuscitation, begin vasopressor therapy 1, 2
• A peripheral inotrope (low-dose dopamine or epinephrine) can be started through a second peripheral IV or intraosseous line while establishing central venous access 1

Vasopressor Selection Based on Shock Type:

• For "cold shock" (narrow pulse pressure, cool extremities, prolonged capillary refill): Use epinephrine 0.05-0.3 mcg/kg/min via central line 1, 3
• For "warm shock" (wide pulse pressure, warm extremities, bounding pulses): Use norepinephrine to increase systemic vascular resistance 1
• Initial peripheral dopamine can be used at low doses (<8 mcg/kg/min) if central access is not yet available, but transition to central administration as soon as possible 1, 4

Dosing for This 33kg Child:

• Epinephrine: Start at 0.05 mcg/kg/min (1.65 mcg/min), titrate up to 0.3 mcg/kg/min (9.9 mcg/min) as needed 1, 3
• Dopamine: 5-10 mcg/kg/min (165-330 mcg/min) for inotropic support 1, 4

Therapeutic Endpoints

Target the following clinical parameters:

• Capillary refill ≤2 seconds 1, 2
• Normal pulses with no differential between peripheral and central pulses 1
• Warm extremities 1, 2
• Urine output >1 mL/kg/hr (>33 mL/hr for this child) 1, 2
• Normal mental status 1, 2
• Normal blood pressure for age (systolic BP >80 mmHg for a 7-year-old) 1, 2
• Arterial oxygen saturation >95% 1, 2
• Central venous oxygen saturation (ScvO2) >70% if central line is placed 1, 2

Critical Pitfalls to Avoid

Common Errors:

• Delaying fluid resuscitation while waiting for laboratory results or imaging—begin treatment based on clinical assessment 2
• Inadequate fluid volume—children in shock often require much more fluid than anticipated (40-200 mL/kg in the first hour) 1
• Failure to recognize persistent shock after initial fluid bolus—reassess perfusion after each intervention 2
• Stopping vasopressors prematurely based on laboratory values rather than clinical perfusion parameters 1
• Using hypotonic fluids—only isotonic crystalloid should be used for shock resuscitation 1

Advanced Interventions:

• If shock persists despite 40 mL/kg of fluid and vasopressor support, consider elective intubation, central venous catheter placement, and transfer to pediatric intensive care 1
• Correct hypoglycemia and hypocalcemia, which can worsen shock 1
• Consider hydrocortisone if absolute adrenal insufficiency is suspected (purpura fulminans, prior steroid exposure) 1