Shock Management in Pediatrics

Definition and Key Concepts

Classification of Pediatric Shock

Recognition: Clinical Features

• Tachycardia (most sensitive, earliest sign)
• Capillary refill >2 seconds (cold peripheries in cold/vasoconstrictive shock)
• Mottled skin, pallor, cool extremities
• Decreased urine output (<1 mL/kg/hr)
• Mild agitation or irritability

• Hypotension (BP <5th percentile for age) - a LATE sign
• Altered mental status, obtundation
• Marked tachycardia or bradycardia (ominous)
• Weak/absent peripheral pulses
• Toxic appearance

Normal Vital Signs by Age (Reference)

Septic Shock - Definitions

• Sepsis: Infection + SIRS criteria (abnormal temp or WBC, tachycardia or tachypnea) + evidence of hypoperfusion or organ dysfunction
• Septic Shock: Hypotension refractory to ≥40 mL/kg IV fluids within 1 hour
• Cold shock: Low cardiac output, vasoconstriction, cold extremities, delayed cap refill
• Warm shock: High cardiac output, vasodilation, warm extremities, flash cap refill (bounding pulses)

General Management Principles (The "Hour-1 Bundle")

1. Timely vascular access
2. Rapid fluid resuscitation titrated to patient condition
3. Appropriate broad-spectrum antibiotics
4. Individualized vasoactive agents to reverse shock

Step 1: Vascular Access

• Large-bore peripheral IV is first choice; do NOT delay for central line placement
• Intraosseous (IO) access if IV fails - all resuscitation drugs/fluids can be given via IO
• Vasoactive agents CAN be administered via peripheral IV or IO to correct shock until central access is established - Rosen's EM, p. 3114

Step 2: Fluid Resuscitation

• Push-pull inline syringe or pressure bag to achieve rapid bolus delivery
• Monitor closely for fluid overload - stop fluids for new tachypnea or hepatomegaly
• Albumin and starches are NOT routinely recommended in ED septic shock resuscitation
• Maximum recommended in resource-limited settings: 40 mL/kg in the first hour
• Lactate >4 mmol/L is associated with increased 30-day mortality (OR 3.3) - Rosen's EM, p. 3113

Step 3: Antibiotics (Septic Shock)

• Blood and urine cultures should be obtained but must NOT delay antibiotic administration
• Bundle compliance (cultures + fluids + antibiotics within 1 hour) reduces mortality OR = 0.59 - Rosen's EM, p. 3114

Step 4: Vasoactive Agents

Step 5: Corticosteroids

• Consider hydrocortisone 1-2 mg/kg IV (max 100 mg) for catecholamine-resistant shock
• Evidence is limited but reasonable by extrapolation from adult data
• A retrospective study found possible increased mortality with hydrocortisone in catecholamine-resistant shock - weigh risks carefully
• The 2020 Surviving Sepsis Campaign states: hydrocortisone may be considered under these circumstances - Rosen's EM, p. 3114

Shock Type-Specific Management

Hypovolemic Shock

• Aggressive isotonic crystalloid boluses (20 mL/kg x 3)
• For hemorrhagic shock: damage-control resuscitation with blood products (pRBCs + FFP in 1:1 ratio)
• Address the underlying cause (surgical hemorrhage control, etc.)

Septic / Distributive Shock

• As per the Hour-1 Bundle above
• Warm shock responds well to norepinephrine
• Cold shock responds well to epinephrine ± dopamine

Cardiogenic Shock

• Cautious fluids (5-10 mL/kg only) - excessive fluid causes pulmonary edema
• Norepinephrine first-line vasopressor (supports SVR)
• Dobutamine added for inotropic support
• Milrinone as a phosphodiesterase inhibitor for low-output states
• Avoid dopamine as first-line due to arrhythmogenic risk
• Furosemide 0.5-1 mg/kg for pulmonary congestion
• CPAP/BiPAP to reduce work of breathing before intubating
• Cardiology consultation; echocardiogram urgently - Rosen's EM, p. 3212

Obstructive Shock

• Tension pneumothorax: Immediate needle decompression (2nd ICS MCL), then chest drain
• Cardiac tamponade: Pericardiocentesis
• Massive PE: Anticoagulation ± thrombolysis

Anaphylactic Shock

• Epinephrine IM 0.01 mg/kg (max 0.5 mg) first-line, immediately
• IV fluid bolus 20 mL/kg
• Diphenhydramine + corticosteroids as adjuncts (not first-line)
• Epinephrine infusion for refractory cases

Monitoring Response to Treatment

• Lactate clearance: Target <2 mmol/L within 3-4 hours - associated with reduced organ dysfunction (RR = 0.46) - Rosen's EM, p. 3114
• Urine output (target >1 mL/kg/hr)
• Normalization of HR and cap refill
• Improved mental status
• Mixed venous O2 saturation, CVP, and cardiac output monitors are not routinely required in the ED
• Passive leg raise may predict fluid responsiveness but evidence is limited in pediatric sepsis
• Bedside echocardiography emerging for refractory shock (41-71% of septic children have myocardial dysfunction)

Blood Glucose Management

• Children are more prone to hypoglycemia than adults (limited glycogen stores)
• Always check glucose early and correct hypoglycemia
• For hyperglycemia >180 mg/dL (10 mmol/L): cautious insulin with frequent glucose monitoring
• Tight glycemic control is NOT superior to conventional control in critically ill children - Rosen's EM, p. 3114

2025-2026 Evidence Updates

Important recent guidelines:

• Surviving Sepsis Campaign 2026 Pediatric Guidelines [PMID: 41869844] (Weiss SL et al., Pediatr Crit Care Med, April 2026) - the most current international guidelines specifically for pediatric sepsis/septic shock management
• AHA/AAP PALS Guidelines 2025 [PMID: 41122885] (Lasa JJ et al., Circulation, October 2025) - updated pediatric advanced life support for shock and cardiac arrest
• Vasopressor strategy meta-analysis 2024 [PMID: 39158574] (Marchetto et al.) - systematic review of vasoactive strategies in pediatric fluid-refractory septic shock

Quick Reference: Pediatric Septic Shock Algorithm

RECOGNIZE (tachycardia + poor perfusion ± hypotension)
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VASCULAR ACCESS (large-bore IV or IO within minutes)
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FLUID BOLUS: 20 mL/kg LR over 10-20 min → reassess
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ANTIBIOTICS: within 1 hour (+ blood/urine cultures)
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Repeat bolus up to 60 mL/kg total → reassess each time
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Still in shock OR signs of fluid overload?
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EPINEPHRINE 0.05 mcg/kg/min (or norepinephrine)
titrate up; add 2nd agent if needed
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Still refractory?
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HYDROCORTISONE 1-2 mg/kg IV (max 100 mg)
Check/correct glucose, consider ICU transfer

• Hypotension is a late sign in pediatric shock - do not wait for it
• IO access is life-saving when IV fails - use it early
• Balanced crystalloids (LR) are preferred over normal saline
• Epinephrine or norepinephrine are preferred over dopamine as first-line vasopressors
• Bundle compliance (abx + fluids + cultures within 1 hour) saves lives
• Always check glucose early in any child with shock