Pediatric shock

This page is for pediatric patients. For adult patients, see: undifferentiated shock

Background

Important physiologic differences between pediatric and adult patients

Intravascular volume
  • Newborns: larger total body water compared to adults (75% vs. 60%) with the majority of it being in the extracellular fluid (ECF) (~40% vs. 25%) 
    • Percentage of ECF decreases throughout childhood
  • Large surface area to weight ratio --> younger kids may have more fluid losses from ECF and intravascular space with short illness/environmental exposure decreased preload
    • May present profoundly volume depleted and need more aggressive volume repletion

Cardiovascular
  • Infants have immature myocardial calcium regulation system, difficulty storing/releasing calcium highly dependent on extracellular calcium for contractility
    • Check iCal, replete calcium earlier, do NOT give CCBs to infants with tachydysrhythmias
  • Stiffer, less compliant myocardium in infants-->increasing heart rate is main compensatory means for increasing BP
    • BUT higher resting heart rate--> less room to go up (e.g. adult with resting heart rate of 60 can double to 120 but a neonate doubling resting heart rate of 120 to 240 is not sustainable)
    • Heavily rely on vasoconstriction, which can further decrease cardiac output
  • Less beta-adrenergic receptors/sympathetic innervations + more dominant parasympathetics --> exaggerated vagal response
  • Hypotension is a ‘’’late’’’ finding in shock!

Clinical Features
  • Signs/symptoms of underlying pathology

Cold shock
  • More common in children than in adults
  • Poor cardiac output due to decreased stroke volume--> tachycardia to compensate
  • Poor peripheral perfusion, increased SVR (vasoconstriction) to compensate-->
    • Skin cold to touch
    • Diminished pulses
    • Mottled skin
    • Cap refill >2s
    • Narrow pulse pressure, eventually hypotension
    • Signs and symptoms of end organ damage as blood shunted to vital organs

Warm shock
  • Hyperdynamic state, with vasodilation and low SVR
  • Results in end organ damage due to shunting of blood away from vital organs to periphery
  • Findings thus include:
    • Tachycardia
    • Wide pulse pressure
    • Bounding peripheral pulses
    • Brisk cap refill

Shock index

Differential Diagnosis
  • Hypovolemia
    • More common and more profound in peds
    • hemorrhage,

dehydration (from nausea/vomiting, insensible losses due to heat illness_)

Sick Neonate

THE MISFITS [1]

Evaluation

Management

Disposition
  • NICU/PICU

See Also
  • Shock


References

https://rebelem.com/approach-to-the-critically-ill-child-shock/ https://pedemmorsels.com/epinephrine-for-shock/ https://www.chop.edu/clinical-pathway/sepsis-emergent-care-clinical-pathway

  1. Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006 Feb;53(1):69-84, vi.
  2. Ramaswamy KN1, Singhi S, Jayashree M, Bansal A, Nallasamy K. Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock. Pediatr Crit Care Med. 2016 Sep 23.
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