Shock in children

Shock in children is a life-threatening condition characterized by inadequate tissue perfusion and oxygen delivery to meet metabolic demands. It is categorized as hypovolemic, distributive, cardiogenic, and/or obstructive based on the underlying mechanism, although multiple mechanisms can coexist. Clinical features depend on the type of shock and degree of compensation and include tachycardia or bradycardia, altered mental status, tachypnea, and hypotension. Management aims to rapidly restore tissue perfusion and oxygen delivery by immediately stabilizing the patient while simultaneously identifying and treating the underlying cause. Hemodynamic support for shock in children includes fluid resuscitation for patients with signs of volume depletion and vasoactive medications for fluid-refractory shock and cardiogenic shock. The prognosis depends on the underlying etiology and timeliness of intervention, with multiple organ dysfunction syndrome being a significant complication.

Poisoning in children (e.g., with dihydropyridine calcium channel blockers or beta blockers) can lead to shock through multiple mechanisms and manifest with cardiogenic and/or distributive shock. ^[8]

Shock in children may manifest with any of the following clinical features: ^[2][8]

• Tachycardia or bradycardia ^[9]
• Hypotension (a late finding)
• Hyperthermia or hypothermia
• Altered mental status and/or irritability
• Poor feeding
• Decreased urine output
• Tachypnea
• Signs of poor peripheral perfusion (e.g., in cardiogenic and hypovolemic shock)
• Warm extremities (e.g., in early septic shock)

Approach ^[2][9][10]

Begin the following simultaneous interventions in consultation with pediatric critical care and other specialists (e.g., cardiology) as indicated.

• Stabilize the patient, e.g.:
  • Perform an ABCDE survey.
  • Apply continuous telemetry and pulse oximetry; perform frequent blood pressure checks. ^[11]
  • Initiate management of respiratory distress and failure in children.
  • Establish immediate vascular access. ^[10][11]
  • Administer hemodynamic support for shock in children.
• Deliver time-critical targeted interventions, e.g.: ^[3][12]
  • Suspected infectious cause: hour-1 bundle for children with sepsis
  • Anaphylaxis: epinephrine ^[13]
  • Cardiogenic shock: inotropes (see "Management of cardiogenic shock in children") ^[3][7][14]
  • Active bleeding: hemostatic methods
  • Tension pneumothorax: emergency chest decompression
  • Cardiac tamponade: therapeutic pericardiocentesis
  • Unstable tachycardia: synchronized cardioversion ^[3]
  • Seizures: initial stabilization for acute seizures ^[9]
  • Correction of electrolyte abnormalities (e.g., hypoglycemia, hypocalcemia) ^[11]
• Perform diagnostics for shock in children to identify the type of shock and underlying cause.
• Tailor subsequent management to the underlying cause, e.g.:
  • Management of sepsis in children
  • Management of cardiogenic shock in children
  • Management of anaphylaxis
  • Management of poisoning in children

Shock can progress to cardiac arrest, and CPR in children may be required. ^[15]

Multiple pathophysiological mechanisms can coexist (e.g., hemorrhagic hypovolemia with tension pneumothorax due to trauma); overlapping presentations may be subtle and complicate early hemodynamic evaluation. ^[3]

Clinical evaluation

History ^[2]

• Signs of specific causes of shock, e.g.:
  • Septic: recent fever and/or symptoms of infection
  • Hypovolemic: vomiting, diarrhea
  • Cardiogenic: clinical features of heart failure in children ^[14]
  • Hemorrhagic: trauma, bleeding
  • Anaphylactic: rash; swelling of the face, mouth, and/or airway
• Past medical history, e.g.:
  • Birth history
  • Congenital heart defects
  • Chronic heart failure ^[14]
  • Endocrine disorders (e.g., hypothyroidism, adrenal insufficiency)
  • Immunosuppression
• Exposure (e.g., insect sting; new food, medication, or substance) ^[16]

Physical examination ^[2]

• General appearance ^[11]
• Pediatric vital signs
• Urine output ^[2]
• Signs of poor peripheral perfusion
• Clinical features of respiratory distress in children ^[2]
• Features of the underlying cause, e.g.: ^[4][11][16]
  • Abnormal cardiopulmonary examination (e.g., in cardiac tamponade, tension pneumothorax, acute heart failure)
  • Abnormal neurological examination in neurogenic shock
  • Signs of bleeding and/or trauma in hemorrhagic shock
  • Urticaria and/or angioedema in anaphylactic shock

Hypotension is a late finding of shock in children because they maintain blood pressure during early shock by increasing systemic vascular resistance. ^[2][8]

Maintain a high level of suspicion for septic shock, especially in infants < 3 months of age. ^[2]

Diagnostics for shock in children ^[2][9][11]

Routine studies

The following studies can identify underlying causes and assess for end-organ damage in all types of shock.

• CBC
• CMP
• Serum lactate ^[2]
• Blood gas
• Coagulation studies
• Point-of-care glucose
• Point-of-care ultrasound (e.g., focused assessment with sonography for trauma)

Targeted studies based on suspected cause ^[2][9]

• Sepsis ^[10]
  • Blood cultures
  • Cultures and/or imaging of the suspected source of infection
  • See also "Diagnostics for pediatric sepsis."
• Anaphylaxis: Serum tryptase can confirm anaphylaxis. ^[16]
• Acute heart failure ^[3][7][14]
  • NT-proBNP
  • Echocardiography
  • ECG
  • See also "Diagnostics for acute heart failure in children."
• Hemorrhage
  • Type and screen
  • Imaging to identify the source of bleeding ^[17]
• Neurogenic shock: imaging at the suspected site of injury ^[4]
• Obstructive causes of shock: imaging (e.g., chest x-ray for pneumothorax, CT scan for pulmonary embolism)
• Metabolic abnormalities
  • Thyroid function testing for suspected severe hypothyroidism
  • Cortisol level for suspected adrenal crisis
• Poisoning
  • ECG
  • Drug levels

IV fluid resuscitation ^[2][3][10]

• Clinical features of acute heart failure: Consult cardiology urgently for management of cardiogenic shock in children.
• Clinical features of volume depletion
  • Rapidly administer a 10–20 mL/kg isotonic crystalloid bolus. ^[3][18]
  • Suspected hemorrhagic shock: Prioritize blood products over isotonic crystalloids when available. ^[3][12]
  • Assess response continuously using hemodynamic monitoring for shock in children.
    • Repeat bolus as needed up to 40–60 mL/kg in the first hour. ^[10]
    • Do not administer further boluses if signs of fluid overload develop or shock resolves.
    • Persistent shock after 40–60 mL/kg isotonic crystalloids: Start vasoactive therapy. ^[2][10]
  • When shock resolves, transition IV fluids to 10% dextrose-containing isotonic crystalloids with potassium supplementation at maintenance fluid rates as indicated. ^[11][19]

Vasopressors ^[3]

• Indications
  • Shock refractory to IV fluid resuscitation
  • Cardiogenic shock in children
• Agents
  • Choose agents based on clinical presentation, including shock type and hemodynamic parameters.
  • Preferred options for septic shock: epinephrine or norepinephrine ^[3][10]
  • Options for cardiogenic shock include epinephrine, milrinone, dopamine, and dobutamine. ^[3][7]
• Next steps
  • Titrate vasopressors based on hemodynamic monitoring for shock in children.
  • Consider additional interventions.

Additional interventions ^[3][10]

• Corticosteroids
  • Consider in patients with septic shock refractory to fluids and vasopressors. ^[3]
  • Indicated as part of the management of adrenal crisis in children ^[20]
• Extracorporeal membrane oxygenation may be indicated for shock refractory to other strategies. ^[2]

The choice of hemodynamic monitoring technique should be based on clinical presentation and availability. Follow hospital protocols and consult a specialist to determine adequate response to therapy. ^[2][10]

• Clinical measures
  • Heart rate
  • Blood pressure
  • Signs of end-organ hypoperfusion (e.g., capillary refill time, mental status)
  • Urine output
• Laboratory and imaging measures
  • Lactate ^[2][10]
  • Echocardiography or POCUS ^[10]
• Invasive hemodynamic monitoring
  • Central venous oxygen saturation: In children with septic shock and central venous access, a target of ≥ 70% is recommended. ^[10]
  • Other advanced monitoring parameters include cardiac index, cardiac output, and systemic vascular resistance index. ^[10]

Assess multiple hemodynamic parameters, and repeat frequently. ^[2][10]

• Multiple organ dysfunction syndrome ^[21]
• Acute kidney injury ^[22]
• Acute respiratory distress syndrome ^[22]
• Acute liver injury ^[23]
• Coagulopathies
  • Trauma-induced coagulopathy ^[12]
  • Thrombocytopenia-associated multiple organ failure ^[22]
• Myocardial dysfunction ^[3]

We list the most important complications. The selection is not exhaustive.