2.16P Shock - Pediatric

Any patient with signs, symptoms, and history suggesting inadequate tissue perfusion should be considered to be in shock. Make every effort to determine and treat the underlying cause. Regardless of etiology, shock patients should be transported immediately to the nearest appropriate facility for definitive care. 

BASIC STANDING ORDERS

• 1.0 Routine Patient Care

• Keep the patient supine.

• Prevent heat loss by covering with warm blankets if available and if the patient is not febrile.

Distributive Shock:

If patient has history of adrenal insufficiency, manage according to protocol 2.1 Adrenal Insufficiency.  

If suspected anaphylaxis, manage according to protocol.

If neurogenic shock is suspected: Spinal immobilization.

Hypovolemic Shock:

Control active bleeding using direct pressure, pressure bandages, tourniquets (commercial tourniquets preferred), or hemostatic bandage.

ADVANCED EMT STANDING ORDERS

Distributive Shock:

• Obtain vascular access. Therapeutic end-points to fluid resuscitation (in order of importance) are: 

• Capillary refill,

• Normal pulses, 

• No difference between peripheral and central pulses,

• Warm extremities, Normal mental status, and

• THEN normal blood pressure.

• Consider 20 ml/kg Normal Saline fluid bolus.

Hypovolemic Shock:

• Obtain vascular access. Therapeutic end-points to fluid resuscitation (in order of importance) are: 

• Capillary refill,

• Normal pulses, 

• No difference between peripheral and central pulses,

• Warm extremities, Normal mental status, and

• THEN normal blood pressure.

• Consider 20 ml/kg Normal Saline fluid bolus.

Obstructive Shock:

• Consider 20 ml/kg Normal Saline fluid bolus.

PARAMEDIC STANDING ORDERS

• Consider fluid administration

• If signs and symptoms of hypoperfusion persist or symptoms worsen, regardless of etiology, consider norepinephrine or dopamine administration via length-based resuscitation tape in the absence of hemorrhagic shock, with medical control approval. 

MEDICAL CONTROL MAY ORDER

• Norepinephrine infusion: 0.1 mcg/kg/min IV/IO, titrate to goal Systolic Blood Pressure of 90mmHg, OR

• Dopamine 2-20 mcg/kg/min IV/IO

• Needle decompression for tension pneumothorax.

NOTES:

Etiology of Shock

• Cardiogenic Shock: History of cardiac surgery, rhythm disturbances, or post cardiac arrest. Assess for acute MI and pulmonary edema.

• Signs & Symptoms of cardiogenic shock: chest pain, shortness of breath, crackles, JVD, hypotension, tachycardia, diaphoresis.

• Distributive Shock: Anaphylaxis (see 2.2 Allergic Reaction/Anaphylaxis), neurogenic shock, sepsis. Assess for fever and signs of infection.

• Signs & Symptoms of neurogenic shock: sensory and/or motor loss, hypotension, bradycardia versus normal heart-rate, warm, dry skin.

• Hypovolemic Shock: Dehydration, volume loss, or hemorrhagic shock.

• Signs & Symptoms of hypovolemic shock: tachycardia, tachypnea, hypotension, diaphoresis, cool skin, pallor, flat neck veins.

• Obstructive Shock: Consider tension pneumothorax, pulmonary embolism, and cardiac tamponade.

• Signs and symptoms of tension pneumothorax: asymmetric or absent unilateral breath sounds, respiratory distress or hypoxia, signs of shock including tachycardia and hypotension, JVD, possible tracheal deviation above the sternal notch (late sign).

For patients with uncontrolled hemorrhagic or penetrating torso injuries:

• Restrict IV fluids.  Delaying aggressive fluid resuscitation until operative intervention may improve the outcome.

• Patients should be reassessed frequently, with special attention given to the lung examination to ensure volume overload does not occur.

• Several mechanisms for worse outcomes associated with IV fluid administration have been suggested, including dislodgement of clot formation, dilution of clotting factors, and acceleration of hemorrhage caused by elevated blood pressure.