Primary assessment as before, but noting the following:
For circulatory access, a short, wide-bore peripheral venous or intraosseous cannula should be used. Upper central venous lines are unsuitable because of the risk of iatrogenic pneumothorax. Femoral vein access is safer, if other access is impossible. It is wise to obtain 2 separate IV and/or IO lines.
Septicaemia is the commonest cause of a child presenting in shock, so unless an alternative diagnosis is very clear (eg trauma) an antibiotic, usually a 3rd generation cephalosporin such as cefotaxime is given as soon as a blood culture has been taken. An anti-staphyloccocal antibiotic (fluclox or vanc) should be considered in possible toxic shock syndrome ie post burns/cellulitis.
Hypoglycaemia should be excluded by glucose stick test. Shock and hypoglyacemia may coexist as the sick infat or small child has poor reserves.
Key features:
Circulatory collapse may present without vomiting and diarrhoea, if there is sudden massive loss of fluid into the bowel lumen before stool is passed.
If still signs of shock after first bolus give a second 20 ml/kg bolus of crystalloid. If there is suspitcion of a surgical abdominal problem, seek an urgent surgical opion. An AXR and USS may be helpful.
If a third bolus is necessary it should be colloid (human albumen is most widely used) and:
The cardinal sign of meningococcal septicaemia is a purpuric rash in an ill child. At the onset, however, the rash is not florid and a careful search should be made for purpura. In 13% of patients with meningococcal septicaemia there is a blanching erythematous rash and in 7% no rash occurs.
In toxic shock syndrome the initial clinical picture includes high fever, headache, confusion, conjunctival and mucosal hyperaemia, scarlatiniform rash with secondary desquamation, subcutaneous oedema, vomiting and watery diarrhoea.
Other investigations should include calcium, magnesium, phosphate, coagulation and ABG. Electrolyte and acid-base derangements may affect myocardial function.
If still shock after the first bolus give a second 20 ml/kg bolus over 5-10 minutes. In septicaemia it remains usual practice to give fluid as 4.5% human albumin.
If a third bolus of fluid is required, the patient should be:
In case of coexistent meningitis, potentially with raised intracranial pressure, assessments of disability must be made: level of consciousness, pupil size and reaction, presence of abnormal posturing. If deteriorating despite treatment of shock, the patient should be intubated and ventilated to achieve pCO2 4-4.5 kPa. A diuretic such as mannitol (0.5-1 g/kg) can be given intravenously. Child should be catheterized.
If such a patient is still shocked then treatment of the shock takes priority. An adequate blood pressure is necessary to perfuse a swollen brain. LP must be avoided.
Most commonly due to penicillin, contrast media, nuts. Prodromal symptoms of flushing, itching, facial swelling, urticaria, abdominal pain, wheeze and stridor may preced shock. Most patients will have a history of previous attacks and may have a "Medic-Alert" bracelet.
Severe reactions are associated with:
Intramuscular route is preferred for epinephrine. IV should be reserved for children with life-threatening shock for whom IM injection has been ineffective. Requires careful monitoring.
Remove allergen if possible. Reassess airway and breathing in case of stridor (give nebulised and IM epinephrine) or wheeze (give nebulised salbutamol and IM epinephrine).
For shock, give colloid 20 ml/kg IV/IO plus IM epinephrine 10 mcg/kg. Additional inotropes will not be needed as epinephrine is a powerful inotrope. However, in the face of shock resistant to IM epinephrine and 1 or 2 boluses of fluid, an infusion of IV epinephrine may be life-saving (0.1-5 mcg/kg/min). Monitor pulse and BP closely.
It is customary to give an antihistamine and steroids but there is no evidence of the part these drugs play in management and their onset of action is too delayed to be of benefit in the first hour.
| Chlorpheniramine doses | |
| >12 yrs | 10-20 mg |
| 6-12 yrs | 5-10 mg |
| 1-5 yrs | 2.5-5 mg |
| 1 month - 1 year | 250 mcg/kg |
| Hydrocortisone | 4 mg/kg |
Babies with critical pulmonary obstructive lesions present in the first few days of life with increasing cyanosis, breathlessness or shock. There may be a murmur but more frequently there is not. An enlarged liver is common.
Babies with critical systemic obstructive lesions also present in the first few days of life with inability to feed, breathlessness, a grey appearance and collapse with poor peripheral circulation. All pulses are difficult to feel.
IV Alprostadil at 0.05 mcg/kg/min will maintain or increase the patent arteriosus ductus size temporarily until the patient can be transferred to a neonatal cardiology unit. The baby should be intubated and ventilated because the prostaglandin can cause apnoea.
FBC, U+Es, Ca, glucose and ABG should be done. A routine infection screen including blood cultures is also recommended. A full 12 lead ECG and CXR are essential.
A diuretic such as frusemide should be given and an infusion of dobutamine (vasodilator plus inotrope) started.
Urgent cardiology advice should be sought; echo will establish diagnosis.
FBC, U+Es, Ca, glucose and ABG should be done. A routine infection screen including blood cultures is also recommended. A full 12 lead ECG and CXR are essential.
Typically a child with sickle cell disease develops septicaemia. Treatment involves volume support, intubation and inotropes. However, the volume infused should be fresh blood as soon as it can be obtained. These children often have an already damaged myocardium predisposing to cardiogenic shock. An exchange transfusion may be life-saving in selected cases.
Prerenal failure, acute tubular necrosis and the more severe cortical necrosis may be sequelae. Fluid administration should be reviewed and serum electrolytes, urea and creatinine analysed.
Shock lung: respiratory failure because of increased water. Ventilation is necessary.
Even if shock was not primarily cardiogenic, poor myocardial perfusion often leads to poor contractility. Inotropes and vasodilators may be required.
Microvascular clotting may lead to a consumption coagulopathy. Clotting times and a platelet count should be estimated and fresh frozen plasma given if clinically indicated.
Liver and bowel may be damaged leading to GI bleeding. Endocrine organs may be variously affected and glucose and mineral homoeostasis must be monitored.
Those who support colloid resuscitation emphasise the importance of oncotic pressure in maintaining intravascular volume and tissue perfusion. Those who favour crystalloids respond that as the endotherlium becomes leakier in ill paitents, the colloid will also leak and serve to retain fluid in the tissues. To equal the increase of intravascular volume produced by a colloid approx 3-5 times as much crystalloid must be given.
Colloids are in general more expensive than crystalloids and human albumin solution is the most expensive and most restricted in availability. Anaphylactic reactions are more common with colloids esp gelatine-based.
If blood is needed it may be given after full cross match wich takes about 1 hour to perform. In more urgent situations type-specific non-cross matched blood should be requested (about 15 min to prepare). In dire emergencies O negative blood must be given.
Fluids should be warmed if this can be done without delay.
A recent Cochrane review suggested that use of albumin increased mortality but there were few paediatric trials included and many of the studies were not done in the emergency situation. A further Cochrane review found no evidence that any colloid was more effective than any other.
In acute collapse, a smaller volume of colloid is needed than crystalloid to produce a given increase in intravascular volume, and so more rapid correction of haemodynamic derangement may be possible with colloid if readily available. When larger volumes of fluid are used, the choice of fluid becomes more important. As more fluid is transfused, the more haemodilution may result, and consideration should be given to using blood for fluid resuscitation with measurements of central venous pressure to guide resuscitation. Where large volumes are used human albumin solution is generally prefered in paediatric pratice although most adult patients are resuscitated with synthetic colloids, crystalloid, or hypertonic solutions.