Management of Shock
Getting oxygen to the organs and tissues is the primary goal of shock management. To achieve this, the blood must have enough oxygen, it must be able to get to the tissues, and the vasculature must have the blood kept within it. Achieving these three important goals is the priority of shock management. The person must be returned to an age-appropriate heart rate and blood pressure, restored mental status, capillary refill, normal pulses, and a minimum of 1 mL/kg an hour output of urine, in objective terms. Etiology determines shock treatment.
Hypovolemic Shock
Providing additional volume is the primary means of responding to hypovolemic shock. Lactated Ringer’s or a normal saline (an isotonic crystalloid) is the preferred fluid in resuscitating volume in children. When administering intravenous fluids to infants and children, there must be great care involved, as opposed to the somewhat straightforward nature of volume repletion in adults. The degree of deficit, the size of the person, and the amount of volume lost (e.g., blood loss) should be considered with careful estimates. Administer 20 mL/kg of fluid as a bolus over 5 to 10 minutes as per current recommendations, and repeat as necessary.
Administer 3 mL of fluid for every 1 mL of estimated blood lost, a 3:1 ratio, in hypovolemic or hemorrhagic shock. Consider without delay the administration of packed red blood cells if the signs of hypovolemic or hemorrhagic shock are not improved by fluid boluses. For additional intravenous volume for trauma, shock, and burns, you may consider albumin as a plasma expander.
Consider reevaluating proper diagnosis and occult blood loss (e.g., into the GI tract) if signs of hypovolemic or hemorrhagic shock are not improved by fluid boluses. Aim to restore electrolyte imbalances (e.g., acid/base, glucose, etc.) with the remaining interventions.
Distributive Shock
Increasing intravascular volume is the initial management of distributive shock. The intent is to overcome the inappropriate redistribution of existing volume by providing enough volume. Administer 20 mL/kg of fluids as a bolus over 5 to 10 minutes, just like hypovolemic shock, and repeat when necessary. Therapy is tailored to the cause of the distributive shock beyond initial management.
Septic Shock
It is necessary to practice aggressive fluid management in septic shock. A key intervention that should be administered immediately is the use of broad-spectrum intravenous antibiotics. Additionally, to support blood pressure, you may need to also employ vasopressors and a stress dose of hydrocortisone (especially with adrenal insufficiency). Depending on the type of septic shock, vasopressors may be given if necessary after fluid resuscitation. Epinephrine treats cold shock, norepinephrine treats warm shock, and dopamine is usually given to normotensive persons. Decreased oxygen-carrying capacity is treated by transfusing packed red blood cells to bring hemoglobin above 10 g/dL. Focus antibiotic therapy to the particular microbe and its resistance patterns as blood cultures return.
Anaphylactic Shock
The first and most important treatment for anaphylactic shock is intramuscular epinephrine. Intravenous administration or a second dose of epinephrine may be required in severe cases. Administer crystalloid fluid judiciously. Capillary permeability may increase significantly while in anaphylactic shock. Third spacing and pulmonary edema is very likely to occur, though it is also important to support blood pressure overall. The anaphylactic response can be blunted by corticosteroids and antihistamines. Consider albuterol use to achieve bronchodilation if breathing challenges arise. It may be required to have a continuous epinephrine infusion in the Neonatal Intensive Care Unit (NICU) or Pediatric Intensive Care Unit (PICU) in very severe cases of anaphylactic shock.
Neurogenic Shock
There is often limited ability to correct the insult, which makes neurogenic shock clinically challenging. Decreased systemic vascular resistance and hypotension are caused by injury to the autonomic pathways in the spinal cord. A clinical sign of neurogenic shock is bradycardia or an inappropriately low pulse. Reassess the person for a response after an initial treatment focusing on fluids first: 20 mL/kg bolus over 5 to 10 minutes. Vasopressors are required if fluid resuscitation does not cause a response in hypotension. A broader neurological evaluation and treatment plan should be done together with this resuscitation.
Cardiogenic Shock
Restoring contractility is the primary goal of therapy, as there is a problem with cardiac contractility in children experiencing cardiogenic shock. A primary intervention in cardiogenic shock is not fluid resuscitation, unlike with most other types of shock. First-line treatments often include medications that reduce afterload and support contractility. This means diuretics and vasodilators in normotensive persons, as both decrease intravascular volume. Inotropes support contractility. Peripheral vascular resistance is often decreased with milrinone. Fluid can be administered cautiously and slowly at 5 to 10 mL/kg over 10 to 20 minutes whenever additional volume is required. Persons with cardiogenic shock should be managed by a critical care specialist or a pediatric cardiologist.
Obstructive Shock
Rapid and definitive care must be administered to causes of obstructive shock, as they are acutely life-threatening. Pericardial drainage is a requirement of cardiac tamponade. Needle decompression and subsequent placement of a chest tube (tube thoracotomy) is required by tension pneumothorax. Pediatric heart surgeons can address vascular abnormalities and prostaglandin E1 analogs can be administered to maintain a patent ductus arteriosus in neonates with ductal-dependent lesions. Trained personnel can administer anticoagulant agents and fibrinolytic, though pulmonary embolism care is mostly supportive. The scope of this handbook does not cover the management of these complex etiologies.