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