Pediatric Shock: Diagnosis and Initial Treatment

Shock in children occurs when the body is receiving insufficient oxygen and nutrients. It can occur with either normal blood pressure or with low blood pressure. It is important to diagnose shock  and start treatment as soon as possible before the blood pressure becomes low (hypotension) because hypotension means the shock is far advanced and the child is in danger of arrest.

Tachycardia (rapid heart rate) and tachypnea (rapid breathing) may be the only abnormalities in early shock (before low blood pressure develop).

A child who appears seriously ill (for example, a child who looks dazed or confused or a child who can’t be comforted by his parent) and has a heart rate of less than 90 beats per minute or a heart rate of greater than 140 beats per minute may have severe compromise that can quickly lead to cardiovascular collapse (arrest). An infant with a heart rate of greater than 180 or less than 90 who can’t focus on his parents or an object may be in shock.

Rapid breathing can also be an early sign of shock. Tachypnea (rapid breathing) depends on the patient’s age. A respiratory rate of more than 60 breaths per minute is always abnormal even in newborns.

Other clues that a infant or child may be in shock are weak pulses, prolonged capillary refill time, pale color and cool temperature of the skin, decreased level of consciousness, and low blood pressure.

Sometimes it is not possible to obtain a blood pressure measurement in a sick infant or child. The doctor can reliably diagnose shock with the other signs and begin treatment. You don’t need a blood measurement to diagnose shock and start treatment.

Pale skin and cool skin can mean inadequate blood flow (shock).

The capillary refill time is the time it takes the skin color to return to normal when a finger is pressed on the skin (usually of the forehead, sternum, or knee cap) and then taken away. Immediately after the finger is removed, the skin underneath will be pale. It should return to normal color (of the surrounding skin) in two seconds or less. If it takes longer than that, it may mean that the body isn’t getting enough blood flow.

Decreased level of consciousness can be a sign of shock (due to the brain not receiving enough blood to function normally). A child with decreased level of consciousness is not responding normally to the environment. He may be appear out of it or he may ignore or not be concerned about the approach of the doctor (normally, child should look at the doctor as she approaches).

Low blood pressure can be a late sign of shock (inadequate blood flow). The doctors’ goal is to diagnose shock early before the blood gets low.

Hypotension (low blood pressure) is a systolic blood pressure (the higher of the two blood pressure numbers) of less than 60 mm Hg in term newborns (of 0 to 28 days).

In Infants from 1 to 12 months old, hypotension is a systolic blood pressure of less than 70 mm Hg.

In children from 1 year old to 10 years old hypotension is a systolic blood pressure of less than the age in years multiplied by two and that quantity added to 70 ([age in years x 2]).

A systolic blood pressure of less than 90 mm Hg in a child greater than 10 years old is hypotension.

When shock is diagnosed, the doctor takes immediate action. First, he makes sure the child’s airway is open and he is breathing adequately. Oxygen is given to the child. The child is connected to a cardiorespiratory monitor to keep track of heart rate and respiratory rate. The child is connected to an oximeter to continuously monitor the oxygen saturation in the blood. An intravenous line is placed in a vein or an intraosseous line is placed in a bone so that fluid and medicine can be given as needed.

If the child is breathing inadequately, the doctor will help the breathing with bag-mask ventilation or with endotracheal tube bag ventilation.

Next post: The Four Causes of Pediatric Shock


Pediatric Advanced Life Support Provider Manual, 2011 American Heart Association

Pediatric Fundamental Critical Care Support, 2008 Society of Critical Care Medicine

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