Pediatric Shock

Definition

  • Shock: Inadequate oxygen delivery to meet metabolic demands
  • Controversy how to diagnose, suspect if
    • Abnormal vitals
      • Hypotension, eg. sBP< 70 + (2 x age)
      • Tachy/bradycardia, Tachypnea
        • For every degree >38C, RR increases by 5, HR increases by 10

Red flags

  • Abnormal vitals
  • <1yo
  • Recent surgery
  • Change in behavior / lethargy / irritability
  • Poor feeding
  • Vomiting
  • Diarrhea
  • Jaundice
  • Hepatomegaly
  • Abdominal distension
  • Prolonged capillary refill

Management

  • ABC
  • DEFG (Don't Ever Forget Glucose)
      • Correct hypoglycemia with D10W 5mL/kg
  • Fluid resuscitate with 20mL/kg IV NS up to 60mL/kg in first hour
    • Watch for hepatomegaly, lung crackles, or ultrasound signs of pulmonary edema
    • For children <2yo, a 30-60mL syringe can be used to manually bolus
  • Antibiotics
    • <1 month
      • Ampi (50 mg/kg for the initial dose) PLUS
        • Genta (2.5 mg/kg for the initial dose) OR Cefotaxime (50 mg/kg for the initial dose)
        • +/- Vanco (15 mg/kg, maximum 1–2 g, for the initial dose) for MRSA
    • >1 month
      • Cefotaxime (100 mg/kg, max 2 g, for the initial dose then 50mg/kg q6h) or Ceftriaxone (75 mg/kg, maximum 2 g, for the initial dose)
        • +/- Vanco for MRSA
        • Gentamicin for GU source
        • Tazocin, Clindamycin, Metronidazole for GI source
    • Other
      • Acyclovir (20 mg/kg per dose) if suspect HSV
      • Antifungal (Ampho B or Caspo)
      • Tetracycline (doxy) if suspect rickettsial infection
  • Investigations
    • CBC
    • Lytes (glucose, creatinine)
    • Capillary glucose as above
    • Blood gas (lactate)
    • Ionized Calcium
      • Treat hypocalcemia early in sepsis with calcium gluconate 10% 0.5-1mL/kg up to 20mL slowly over 5 mins
    • LFT
    • Blood cultures x2
    • UA/Urine culture
    • Consider LP
    • Consider X-ray
  • Fluid-refractory shock (hypotensive despite 60mL/kg of crystalloids)
    • Epinephrine 0.1-1 mcg/kg/min IV/IO infusion for "cold shock"
    • Norepinephrine 0.1-2 mcg/kg/min IV/IO infusion for "warm shock"
    • Early intubation after fluid resuscitation
  • Catecholamine-resistant shock - think adrenal insufficiency
    • Hydrocortisone 2mg/kg IV

Goals

  • Normal vitals (BP, pulse)
  • Normal mental status
  • Warm extremities (Cap refill <2s)
  • Urine output >1mL/kg/h
  • Normal lactate

References:

  • EM Cases