The Shock Index In Pediatrics – Help From Dr. Sean Fox

Just as in adults, the Shock Index in Pediatrics appears helpful in early recognition of septic shock and traumatic shock.

Dr. Sean Fox, of the incredibly helpful Pediatric Emergency Medicine Morsels blog, posts on the Pediatric SHOCK Index MARCH 6, 2015.

Here are some excerpts from that post:

Pediatric Shock: A Challenge

  • The diagnosis is initially suspected based upon clinical exam.
  • There is no lab value or “test” that defines shock. (See Lactate)
  • Clinical Findings:
    • Tachycardia
      • Must account for age-adjusted values!
      • Often children present with elevated heart rates without overt illness.
    • Poor Capillary Refill
      • Normal capillary refill can vary with age and is influenced by the environment. (Schriger, 1988)
      • The initial cap refill in the ED, may artificially affected by the pre-hospital environment.
    • Peripheral Pulse Quality
    • Altered Mental Status
    • Cold/Mottled Extremities
    • Poor Urine Output
      • Not likely useful in the initial assessment in the ED.
      • If the patient is “hanging out” in your ED for some time, monitor this!
  • Of these clinical findings, only Altered Mental Status and Poor Peripheral Pulse Quality was associated with development of Organ Dysfunction. (Scott, 2014)
  • No single finding defines shock, but the absence of all of them is reassuring.


Pediatric Shock: The Shock Index

  • The Shock Index (Heart Rate / Systolic BP) has been shown to be useful in detecting adult patients with shock.
  • There is evidence that the Shock Index can be useful in pediatric patients also. (Yasaka, 2013; Rousseaux, 2013)
  • Since, pediatric vital signs alter with age, it would make sense to have a “adjusted” tool. (Acker, 2015)
    • Using standard heart rate and systolic BP values for age ranges, Maximum Normal Shock Index values were calculated.
    • Shock Index, Pediatric Adjusted (SIPA)
      • 4-6 years = 1.2
      • 6-12 years = 1
      • > 12 years = 0.9
    • Comparing the patient’s actual HR / Systolic BP to the SIPA was shown to perform better and identify those most severely injured following blunt trauma. (Acker, 2015)
  • Obviously, this may not apply to all pediatric patients presenting with shock, but I do like the concept of utilizing Basic information that is age adjusted.
  • Consider utilizing this tool as another method to help find those subtle presentations of shock.  Remain Vigilant!


Additional Resources:
Is shock index associated with outcome in children with sepsis/septic shock? [PubMed Abstract] Pediatr Crit Care Med. 2013 Oct;14(8):e372-9.


Shock index may have promise as a marker of mortality in children with sepsis/septic shock. Although there is no clear cutoff shock index to identify risk of mortality, given the higher risk of mortality as shock index increases, children with elevated shock index may benefit from more aggressive resuscitation and higher level of care

Prognostic value of shock index in children with septic shock. [PubMed Abstract]. Pediatr Emerg Care. 2013 Oct;29(10):1055-9.

Septic shock is frequent in children and is associated with high mortality and morbidity rates. Early recognition of severe sepsis improve outcome. Shock index (SI), ratio of heart rate (HR) and systolic blood pressure (SBP), may be a good noninvasive measure of hemodynamic instability that has been poorly studied in children. The aim of the study was to explore the usefulness of SI as an early index of prognosis for septic shock in children.
The study was retrospective and performed in 1 pediatric intensive care unit at a university hospital. The following specific data were collected at 0, 1, 2, 4, and 6 hours after admission: HR and SBP for SI calculation and lactate concentration. Patients were divided into 2 groups according to their outcome (death/survival).
A total of 146 children admitted with septic shock between January 2000 and April 2010 were included. Shock index was significantly different between survivors and nonsurvivors at 0, 4, and 6 hours after admission (P = 0.02, P = 0.03, and P = 0.008, respectively). Age-adjusted SIs were different between survivors and nonsurvivors at 0 and 6 hours, with a relative risk of death at these time points of 1.85 (1.04-3.26) (P = 0.03) and 2.17 (1.18-3.96) (P = 0.01), respectively. Moreover, an abnormal SI both at admission and at 6 hours was predictive of death with relative risk of 1.36 (1.05-1.76).
In our population of children with septic shock, SI was a clinically relevant and easily calculated predictor of mortality. It could be a better measure of hemodynamic status than HR and SBP alone, allowing for the early recognition of severe sepsis.

Pediatric specific shock index accurately identifies severely injured children. [PubMed Abstract]. J Pediatr Surg. 2015 Feb;50(2):331-4.

Shock index (SI) (heart rate/systolic blood pressure)>0.9 predicts mortality in adult trauma patients. We hypothesized that age adjusted SI could more accurately predict outcomes in children.
Retrospective review of children age 4-16 years admitted to two trauma centers between 1/07 and 6/13 following blunt trauma with an injury severity score (ISS)>15 was performed. We evaluated the ability of SI>0.9 at emergency department presentation and elevated shock index, pediatric age adjusted (SIPA) to predict outcomes. SIPA was defined by maximum normal HR and minimum normal SBP by age. Cutoffs included SI>1.22 (age 4-6), >1.0 (7-12), and >0.9 (13-16).
Among 543 children, 50% of children had an SI>0.9 but this fell to 28% using age adjusted SI (SIPA). SIPA demonstrated improved discrimination of severe injury relative to SI: ISS>30: 37% vs 26%; blood transfusion within the first 24 hours: 27% vs 20%; Grade III liver/spleen laceration requiring blood transfusion: 41% vs 26%; and in-hospital mortality: 11% vs 7%.
A pediatric specific shock index (SIPA) more accurately identifies children who are most severely injured, have intraabdominal injury requiring transfusion, and are at highest risk of death when compared to shock index unadjusted for age.
Copyright © 2015 Elsevier Inc. All rights reserved.

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