Shock Management in Children
1TBD, National Pediatric Hospital San Jose, Costa Rica
Pediatric shock results in a significant amount of morbidity and mortality world-wide. Sepsis and hypovolemia secondary to gastroenteritis are leading causes of child mortality, with an estimated 3 to 5 billion cases of acute gastroenteritis and nearly 2 million deaths occurring each year in children under 5 years of age, with 98% of those deaths occurring developing countries. The early recognition of patients with shock is essential for a prompt treatment and decrease of complications. Rapid identification of the etiology may help to guide specific therapies. Several classifications of shock exist. The most common are hypovolemic shock, distributive shock, cardiogenic shock and obstructive shock. The presence of shock is also associated with worse outcomes in a variety of emergency conditions, including traumatic brain injury and cardiac arrest. At multiple points along the way, POCUS may assist diagnosis and help to guide therapies including assessment of preload, fluid responsiveness, and cardiac function. At each step, reassess for response to treatment. Airway management and ventilatory support is often necessary in children in shock. Often underrecognized, intubation of a child in shock may be indicated for hemodynamic instability alone. Reversal of shock depends on the reestablishment of sufficient oxygen delivery to the body. In the ED, initial therapies should be titrated to normalize vital signs and physical examination abnormalities. Most shock requires some degree of fluid resuscitation. If shock remains refractory to fluids, add inotropes and/or vasopressors. If catecholamine-resistant shock occurs, advanced hemodynamic monitoring may be required to help to titrate therapies. Consider hydrocortisone supplementation. If initial resuscitation with fluids and vasoactive medications do not reverse the shock state, advanced hemodynamic monitoring may be required to guide treatment.