The Child in Shock: Assessment and Treatment

Christopher J. Chiu, MD; Justin L. Berk, MD, MPH, MBA


July 14, 2021

This transcript has been edited for clarity.

Christopher J. Chiu, MD: Welcome back to The Cribsiders. We are the pediatric medicine podcast. From our interviews with leading experts, we bring you clinical pearls and practice-changing knowledge, and answer lingering questions about core topics in pediatric medicine.

Justin L. Berk, MD, MPH, MBA: We had a great conversation about pediatric shock with Dr Sarah Welsh. She's a pediatric critical care doctor and the medical director of the Hasbro Children's Hospital in Providence, Rhode Island, at Brown University. This episode was produced by Dr Jessica Kelly.

Chiu: I want to remind people where shock fits in the spectrum that starts with systemic inflammatory response syndrome (SIRS).

Figure. Systemic inflammatory response syndrome (SIRS) to shock.

SIRS is when you have two or more of the following features: hypothermia or hyperthermia, tachycardia or bradycardia (if the child is less than 1 year old), tachypnea, or an abnormal white blood cell count. Sepsis is SIRS with an infectious source, and severe sepsis involves organ dysfunction. Finally, shock is severe sepsis that doesn't respond to initial resuscitation efforts. Now, as we're looking at sepsis and shock, we're always looking at vitals. And something about vitals is pretty important, right?

Berk: Yes. I thought this was a great episode to not only go through what to do in severe cases, but how to really start thinking about shock early on. One of the major early warning signs we talked about was tachycardia and really paying attention to age-appropriate vital signs, and not waiting until the child is hypotensive to start treatment. Hypotension is really a late finding in shock and is really a sign of uncompensated shock. So the goal is to try to begin treatment before we get to this point.

Chiu: So looking back, we're talking about compensated shock. That is when we see tachycardia or vascular resistance that has increased to prevent hypotension, which is why it's a late finding.

In terms of initial management, we always have to start with the ABCs: airway, breathing, and circulation. Treatment guidelines recommend to start antibiotics within 1 hour of presentation. Fluid boluses should be limited to 60 mL/kg of isotonic fluids, but no more than that, because we really should be thinking about norepinephrine or epinephrine a lot earlier.

Berk: One of the key takeaways for me was about the FEAST trial that was brought up by Dr Welsh. The FEAST trial showed that children who were given more bolus fluids or more normal saline actually did worse. The thought was that repeated normal saline boluses can cause hyperchloremic acidosis. Some of the adult literature shows that lactated Ringer's might be a little bit better as a fluid choice. There's ongoing research in pediatrics, but regardless of the isotonic fluid used, or when you start pressors, reassessment is really the key; you follow the mean arterial pressures, skin perfusion, urination, mental status, and all the other markers for end-organ perfusion that we have as part of our clinical assessment.

Chiu: If you're interested in learning more about shock and sepsis, check out our podcast: Shock! A Deep Dive Into Our First Intensive Topic.

Berk: We appreciate you watching this Medscape video recap of The Cribsiders pediatric podcast episode on shock. You can download the full episode on any podcast player or check out our website. Thanks for joining us.

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