Over the recent past I have been reviewing the diagnosis and treatment of pediatric shock.
Here are some excellent posts related to the subject from Pediatric EM Morsels:
Palpation of Pulse for Cardiac Arrest
BY SEAN FOX · PUBLISHED AUGUST 29, 2014 · UPDATED SEPTEMBER 1, 2014
Systolic Blood Pressure Guide
BY SEAN FOX · PUBLISHED NOVEMBER 26, 2010 · UPDATED FEBRUARY 15, 2013
• Recall that hypotension, as demonstrated by numeric values, is a later finding in children.
• The child that does exhibit low blood pressure readings has progressed down that “slipper slope” of shock to a considerable extent.
• PALS traditionally teaches that your goal SBP ≥ 70 + 2x Age in Years. This equates to approximately the 5 percentile of SBP for weight. Many would consider this still sub-optimal.
• A better goal would be to aim for SBP ≥ 90 + 2x Age in Years. This equates to the 50 percentile of SBP for weight (the Median)
Pediatric SHOCK Index BY SEAN FOX – MARCH 6, 2015
- 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!
Don’t be afraid of PGE1
BY SEAN FOX · PUBLISHED JULY 15, 2011
Epinephrine for SHOCK
BY SEAN FOX · PUBLISHED OCTOBER 7, 2016 · UPDATED JULY 25, 2017
And one of the best pediatric shock posts for me is Epinephrine for Shock. The way to review the post is by reading it through carefully once and then clicking on all the links in the body of the text. By clicking on all those links you will receive a fast and comprehensive review of the recognition and management of shock.
What follows is an outstanding post from Dr. Sean Smith of Pediatric EM Morsels – Epinephrine for Shock, Oct 7, 2016:
Pediatric shock warrants great concern. Whether it is caused by Sepsis [includes other causes of distributive shock – anaphylaxis and neurogenic] , Hypovolemia, Obstructive process (ex, Tamponade, PE, Pneumothorax), Cardiogenic conditions, or “K“ortisol deficiency (Yes, I know it should be “Cortisol”… but then it wouldn’t spell SHOCK.) there are many management decisions to be made. How do we detect shock in those tricky kids? What do we do when access is denied? When do we need to consider PGE1? There are so many questions to consider. Unfortunately, some children in SEPTIC shock will be refractory to your initial therapies and another question will be encountered: Which pressor should we start: Epinephrine or Dopamine?
- Sepsis is a leading cause of mortality worldwide, although improvements have been made.
- Once septic shock is present the mortality can be as high as 50%. [Wolfier, 2008]
- Guidelines published have emphasized the need for:
- Early recognition and
- Rapid fluid administration.
- Keep your Differential open!
- While ordering empiric antibiotics, consider the other causes of SHOCK in children.
- The child with fluid-refractory shock deserves a second and third consideration for the other possible culprits!
- Use your bedside Ultrasound [Doniger, 2010;ALIEM]
Be Aggressive and Rapid!
- The goal of the 1st hour of resuscitation is to restore normal perfusion, blood pressure and heart rate. [Brierley, 2009]
- Vascular access needs to be rapidly attained.
- Large bore peripheral IVs or IOs.
- Central lines play a role in the management of the critically ill, but should NOT divert attention away from more time sensitive tasks.
- Rapidly bolus fluids
- Do not hang to gravity or on a “pump.”
- Use syringe pushes or pressure bags
- Children commonly will require 40-60 ml/kg in the 1st hour, but may require more (some say 200 ml/kg in 1st hour in right clinical setting). [Brierley, 2009]
- Don’t forget about Glucose!
- SERIOUSLY… always think about glucose like you are Homer Simpson thinking about donuts!
Vasopressors can be Started Peripherally
- Do not hesitate to start vasopressors.
- Children with fluid-refractory shock tend to respond to inotropes. [Ceneviva, 1998]
- Reversing shock is associated with better survival.
- Common perception is that vasoactive medications (vasopressors) need to be give via central line.
- In an ideal setting, this is reasonable. That 1st hour of critical illness is often not ideal.
- There is no data clarifying whether one vasopressor is more harmful when given peripherally than another. [Brierley, 2009]
- Epinephrine has been shown to be safe and effective when given via peripheral IV or IO in the setting of Septic Shock. [Ramaswamy, 2016; Ventura, 2015]
- Time is critical; central lines aren’t easy in children; PIVs and IOs work just fine!
Epinephrine vs Dopamine
- Short answer = there is no perfect vasopressor and no perfect answer.
- Traditional teaching and prior guidelines have listed Dopamine as 1st line therapy. [Brierley, 2009]
- Adult literature has raised concerns about safety of Dopamine [De Backer, 2010]
- Dopamine is known to not be as effective in young children (<6 months). [Brierley, 2009]
- Not many pediatric studies compare vasopressors, but today two small, RTC trials exist: Ramaswamy, 2016; Ventura, 2015
- Both compared peripheral Epinephrine vs peripheral Dopamine as 1st choice.
- For children with Fluid-Refractory Shock:
- Epinephrine was more effective in resolving the refractory shock
- Epinephrine resolved shock more rapidly than dopamine
- Survival rates were higher in cohorts receiving epinephrine. [Ventura, 2015]
Additional Resources about Pediatric Shock from Pediatric EM Morsels [These resources are in addition to those links in the body of Dr. Fox’s post]:
Internal and Emergency Medicine
June 2010, Volume 5, Issue 3, pp 253–255
Detection of spontaneous pneumothorax with chest ultrasound in the emergency department
Example of the Sliding Lung Sign.
Lack of it is concerning for Pneumothorax.
Congenital Adrenal Hyperplasia
BY SEAN FOX · PUBLISHED MAY 25, 2012 · UPDATED AUGUST 8, 2013
Inborn Errors of Metabolism presenting in the ED [Discusses what tests to order when IEM is in the differntial]
BY SEAN FOX · PUBLISHED SEPTEMBER 24, 2010 · UPDATED AUGUST 8, 2013
BY SEAN FOX · PUBLISHED MARCH 18, 2011 · UPDATED AUGUST 8, 2013