Initial management of shock in children

Author:
Mark Waltzman, MD
Section Editors:
Susan B Torrey, MD
Adrienne G Randolph, MD, MSc
Deputy Editor:
James F Wiley, II, MD, MPH
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2016. | This topic last updated: May 25, 2016.
INTRODUCTION This topic will review the initial management of children with shock. The
classification of pediatric shock, initial evaluation of shock in children, and management of specific
types of shock are discussed separately:
(See "Physiology and classification of shock in children".)
(See "Initial evaluation of shock in children".)
(See "Systemic inflammatory response syndrome (SIRS) and sepsis in children: Definitions ,
epidemiology, clinical manifestations, and diagnosis".)
(See "Septic shock: Rapid recognition and initial resuscitation in children" and "Septic shock:
Ongoing management after resuscitation in children".)
(See "Hypovolemic shock in children: Initial evaluation and management" .)
DEFINITIONS Shock is a physiologic state characterized by a significant, systemic reduction in
tissue perfusion; resulting in decreased tissue oxygen delivery and diminished removal of harmful
byproducts of metabolism (eg, lactate). According to Pediatric Advanced Life Support (PALS) course,
shock is further classified into the following stages [1] (see "Physiology and classification of shock in
children", section on 'Stages of shock'):
Compensated shock During compensated shock, the body's homeostatic mechanisms
rapidly compensate for diminished perfusion and systolic blood pressure is maintained within
the normal range. Heart rate is initially increased. Signs of peripheral vasoconstriction (such as
cool skin, decreased peripheral pulses, and oliguria) can be noted as perfusion becomes further
compromised.
Hypotensive shock During this stage, compensatory mechanisms are overwhelmed. Heart
rate is markedly elevated and hypotension develops. Signs and symptoms of organ dysfunction
(such as altered mental status as the result of poor brain perfusion) appear. Systolic blood
pressure falls, although children who have lost as much as 30 to 35 percent of circulating blood
volume can typically maintain normal systolic blood pressures. Once hypotension develops, the
child's condition usually deteriorates rapidly to cardiovascular collapse and cardiac arrest.

Irreversible shock During this stage, progressive

end-organ

dysfunction leads to

irreversible organ damage and death. Tachycardia may be replaced by bradycardia and blood
pressure becomes very low. The process is often irreversible, despite resuscitative efforts.
In addition to these stages of shock, four broad mechanisms of shock are recognized: hypovolemic ,
distributive, cardiogenic, and obstructive. Each ty pe is characterized by one primary physiologic
derangement as follows (table 1) (see "Physiology and classification of shock in children", section on
'Classification'):
Hypovolemic Decreased

preload

caused by volume

loss including

hemorrhage,

gastrointestinal losses, insensible losses (eg, burns), or third spacing

Distributive Decreased vascular resistance due to vasodilation caused by conditions such
as sepsis, anaphylaxis, or acute injury to the spinal cord or brain
Cardiogenic Decreased cardiac contractility caused by conditions such as primary
myocardial injury, arrhythmias, cardiomyopathy, myocarditis, congenital heart disease with
heart failure, sepsis, or poisoning
Obstructive Increased vascular resistance caused by conditions such as congenital heart
disease with ductal dependent lesions (eg, hypoplastic left heart), or acquired obstructive
conditions (eg, pneumothorax, cardiac tamponade, or massive pulmonary embolism)
However, a patient may have more than one type of shock (such as an infant with cardiogenic shock
from supraventricular tachycardia who is also hypovolemic because he has been unable to drink or
a child with underlying cardiomyopathy who is septic). (See "Initial evaluation of shock in children",
section on 'Clinical classification of shock'.)
An algorithm for identifying the cause of shock is provided (algorithm 1). Recognition of shock and
classification based upon clinical findings is discussed in detail separately. (See "Initial evaluation of
shock in children", section on 'Evaluation'.)
EARLY GOAL-DIRECTED

THERAPY Early goal-directed therapy for shock refers to an

aggressive systematic approach to resuscitation targeted to improvements in physiologic indicators

of perfusion and vital organ function within the first six hours. Targeted interventions are determined
by degree of illness and response to treatment within the first hour of care. This approach has been
most strongly promoted for children with septic shock. (See "Septic shock: Rapid recognition and
initial resuscitation in children", section on 'Resuscitation'.)
Early goal-directed

therapy for septic shock in adults is discussed in detail separately.

(See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Early
goal-directed therapy targets' and "Evaluation and management of suspected sepsis and septic
shock in adults", section on 'Protocol-directed therapy'.)
Physiologic indicators and target goals Physiologic indicators that should be targeted during
therapy (with goals in parentheses) include [2,3]:

Blood pressure (systolic pressure at least fifth percentile for age: 60 mmHg <1 month of age,
70 mmHg + [2 x age in years] in children 1 month to 10 years of age, 90 mmHg in children 10
years of age or older)
Quality of central and peripheral pulses (strong, distal pulses equal to central pulses)
Skin perfusion (warm, with capillary refill <2 seconds)
Mental status (normal mental status)
Urine output (1 mL/kg per hour, once effective circulating volume is restored)
Heart rate is an important physiologic indicator of circulatory status. For children with shock,
tachycardia is often a compensatory response to poor tissue perfusion. In this situation, a decrease
in heart rate with fluid therapy can be a valuable indic ator of improved perfusion in response to
treatment (table 2). However, many other factors (ie, fever, drugs, hypoxia, and anxiety) influenc e
heart rate. In addition, an abnormal heart rate may be the direct result of the cause of shock (as with
myocarditis or beta blocker ingestion). Although trends in response to treatment should be carefully
monitored, specific target goals for heart rate are difficult to define and may not be useful. (See "Initial
evaluation of shock in children", section on 'Circulation'.)
Elevation of serum or blood lactate (>4 mmol/L) may help identify the severity of shock at
presentation. Although evidence is limited in children, reduction in s erum or blood lactate levels have
been associated with improved survival in adults with shock. Rapid determination of blood lactate
may be obtained at the bedside. (See "Evaluation and management of suspected sepsis and septic
shock in adults", section on 'Early goal-directed therapy targets'.)
Identifying physiologic indicators to monitor the effectiveness of resuscitation for children with shock
is challenging. Parameters that are monitored for adults with sepsis (ie, central venous pressure and
central venous oxygen saturation) require central venous catheterization, which can be technically
difficult and not always practical or appropriate in children.
Noninvasive ultrasonic determination of cardiac index, cardiac output, systemic vascular resistance,
and stroke volume is feasible in healthy children, and age-based normative values have been
published [4]. Although not widely available, bedside Doppler ultrasound shows promise as a
noninvasive method to guide vasoactive therapy by calculating cardiac output (CO) and systemic
vascular resistance (SVR) from measurements of blood flow over the pulmonary artery or aorta. As
an example, in an observational study of children with fluid-resistant septic shock, this method
identified warm shock (high CO, low SVR) and cold shock (low to normal CO, high SVR) in 30 children
and correlated these shock states with the underlying diagnosis; warm shock in children with central
venous catheter related sepsis (15 of 16 patients) and cold shock in those patients with community
acquired sepsis (12 of 14 patients) [5].
Several physiologic indicators can be readily monitored noninvasively during the initial management
of shock and, since many children in shock respond well, invasive monitoring can often be avoided
[2]. Mean arterial pressure can be measured with a blood pressure cuff. Clinical experience suggests
that the quality of central and peripheral pulses, skin perfusion, mental status, and urine output are
useful signs for assessing response to therapy [2,3]. Limited observational evidence suggests that

capillary refill time may correlate with mixed central venous oxygen saturation (ScvO 2), an invas ive
measurement of tissue oxygen extraction. In a prospective study of 21 critically ill children, the
majority of whom had septic shock, a central capillary refill time 2 seconds had a sensitivity of 84
percent and a positive predictive value of 50 percent for a ScvO 2 70 percent suggesting that cardiac
output was providing adequate tissue perfusion [6].
Fluid administration Limited evidence exists concerning the optimal amount and rate of fluid
administration for children with shock. Several studies support the use of isotonic crystalloid fluid
bolus (ie, normal saline or Ringers Lactate) as a component of goal-directed therapy for shock other
than obstructive shock (eg, tension pneumothorax, pericardial tamponade, or massive pulmonary
embolus). However,

aggressive fluid resuscitation may be harmful for children who are not

hypovolemic or have compensated shock with certain comorbidities (eg, cardiac disease, diabetic
ketoacidosis [DKA], syndrome of inappropriate antidiuretic hormone secretion [SIADH], severe
malnutrition, or malaria). Patients with obstructive shock should receive emergent correction of the
underlying

cause (eg, needle or chest tube thoracostomy for tension pneumothorax

or

pericardiocentesis for cardiac tamponade). Neonates with ductal dependent lesions and circulatory
collapse may also be hypovolemic. However, primary treatment should focus on reopening the ductus
arteriosus

with prostaglandin

E 1 (alprostadil).

(See 'Evidence

for

goal-directed

therapy

in

children' below and 'Risks' below and 'Obstructive shock' below.)

The etiology and degree of shock determines the volume and rate of initial fluid resuscitation (table
1) [1-3] (see 'Definitions' above):
Hypotensive hypovolemic or distributive shock We recommend that children with
hypotensive hypovolemic or distributive shock (as from gastrointestinal losses, traumatic
hemorrhage, sepsis, or anaphylaxis), receive 20 mL/kg per bolus of isotonic crystalloid, such as
normal saline or Ringer's lactate solution, infused over 5 to 10 minutes and repeated, as needed,
up to four times in patients without improvement and no signs of fluid overload [2,7,8]. Additional
therapies, such as blood transfusion in patients with hypovolemic shock from hemorrhage or
vasoactive drug therapy and corticosteroid administration in patients with septic shock may be
required depending upon the response to fluid administration. (See 'Hypovolemic shock' below
and 'Distributive

shock' below. )

Observational studies of rapid fluid resuscitation as a component of goal-directed therapy and

in conjunction with other critical care interventions such as prophylactic endotracheal intubation
with mechanical ventilation and close monitoring by pediatric critical care specialists has been
associated with a marked decrease in mortality, especially in children with hypotensive septic
shock.

(See 'Evidence

for

goal-directed

therapy

in

children' below. )

Techniques to rapidly deliver intravenous fluid include gravity, applying pressure directly to the
bag of fluid with an inflatable device, delivering aliquots of fluid using a large syringe that is
refilled through a three-way stopcock attached to the bag (the "push-pull" method) or use of
rapid infusion pumps designed to deliver high volumes of warmed fluids or blood. Gravity alone

is likely insufficient to deliver 20 mL/kg over 5 to 10 minutes. This was demonstrated in a

randomized trial that compared the rate at which fluid could be delivered to 57 children requiring
fluid resuscitation using gravity, an inflatable pressure bag, or a "push-pull" method [9]. The
median volume of fluid delivered over five minutes by gravity was 6.2 mL/kg, in comparison to
20.9 mL/kg for the pressure bag and 20.2 mL/kg for the "push-pull" method. These differenc es
remained significant after controlling for intravenous catheter gauge, age, and weight.
Compensated hypovolemic or distributive shock We suggest that children with
compensated hypovolemic

or distributive shock receive 20 mL/kg per bolus of isotonic

crystalloid, such as normal saline or Ringer's lactate solution over 5 to 20 minutes. Patients
should be closely monitored during fluid administration. Additional fluid boluses m ay be
indicated depending upon the patients response. Evidence suggests that overly aggressive
fluid bolus may be harmful in selected patients, including those with cardiogenic shock, DKA,
syndrome of inappropriate diuretic hormone secretion, severe malnutrition, or, in resourcelimited settings, severe febrile illness in the absence of dehydration or hemorrhage.
(See 'Risks' below.)
Cardiogenic shock For suspected cardiogenic shock in patients with signs such as a gallop
rhythm, pulmonary rales, jugular venous distension, or hepatomegaly, a smaller isotonic
crystalloid fluid bolus of 5 to 10 mL/kg, infused over 10 to 20 minutes decreases the likelihood
of exacerbating heart failure. (See 'Cardiogenic shock' below.)
Diabetic ketoacidosis Children with diabetic ketoacidosis (DKA) should receive careful fluid
resuscitation (one bolus of 10 mL/kg infused over one hour) in order to avoid cerebral edema,
a rare complication of DKA. (See "Treatment and complications of diabetic ketoacidosis in
children", section on 'Cerebral edema'.)
Severe febrile illness in resource -limited settings Children with severe febrile illness
without dehydration or hemorrhage and with normal blood pressure who reside in resource limited settings, where aggressive monitoring, endotracheal intubation with mechanical
ventilation, and vasopressor therapies are not available, and who have no signs of dehydration
or hemorrhage should not receive boluses of isotonic fluid. This approach is associated with
increased mortality when compared with blood transfusion and maintenance fluid therapy alone.
(See 'Risks' below.)
Risks Aggressive fluid replacement may be harmful and should be avoided in patients with the
following conditions:
Cardiogenic shock Although many children with cardiogenic shock have some degree of
hypovolemia, fluids should be administered slowly and in boluses of 5 to 10 mL/kg in such
patients to avoid worsening myocardial insufficiency and pulmonary edema. Clinic al findings of
cardiogenic shock include gallop rhythm, jugular venous distension, pulmonary rales, and
hepatomegaly.
Severe anemia Rapid fluid administration in children with hemoglobin levels below
5 g/dL may further dilute the hemoglobin concentration, impair oxygen delivery, and precipitate
heart failure [10]. Blood transfusion is the preferred therapy in such patients, although careful
fluid administration may be acceptable if transfusion is delayed. As an example, in a small trial

of 38 children with severe falciparum

malaria (hemoglobin <5 g/dL), administration of

20 mL/kg of isotonic saline or 4.5 percent albumin versus maintenance fluid therapy only while
waiting for blood transfusion did not cause congestive heart failure and resulted in significantly
less need for emergency interventions (0 versus 22 percent, respectively) [ 11].
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Aggressive fluid
therapy in the absence of hypovolemia can cause cerebral edema in patients with meningitis
and adult respiratory distress syndrome in patients with pneumonia as a result of fluid overload
caused by SIADH. (See "Pathophysiology and etiology of the syndrome of inappropriat e
antidiuretic hormone secretion (SIADH)", section on 'Etiology'.)
Diabetic ketoacidosis (DKA) Cerebral edema, a rare complication of DKA, usually
develops during treatment and has been associated with rapid administration of fluids. However,
cerebral edema may also occur in optimally managed patients. (See "Treatment and
complications of diabetic ketoacidosis in children", section on 'Cerebral edema'.)
Severe malnutrition Intravenous fluid resuscitation in children with severe malnutrition and
signs of shock is controversial [12]. Sunken eyes, lethargy, and tenting may occur from
malnutrition alone and can cause clinicians to overestimate the degree of dehydration [ 13].
Some experts believe that malnutrition causes sodium and water retention, overexpansion of
the extracellular fluid, and myocardial dysfunction [12,14-16]. Thus, rapid administration of
intravenous fluids to infants and children who do not have fluid depletion or physiologic changes
associated with severe malnutrition or both may risk fluid overload, heart failure, and pulmonary
edema and is not recommended by the World Health Organization (WHO) [ 13,17].
However, evidence suggests that the WHO recommendations for fluid resus citation in severely
malnourished may be too restrictive. For example, in an observational study of fluid resuscitation
in 149 severely malnourished children with cholera and severe dehydration, infusion of
approximately 20 mL/kg per hour of an isotonic saline solution over four to six hours was not
associated with heart failure in any patient, and all patients survived [ 18]. Furthermore, in a
clinical trial of 61 children with severe malnutrition accompanied by decompensated shock in
the majority of patients, administration of 30 to 40 mL/kg of crystalloid fluids over two hours
failed to reverse shock in over half of patients and was accompanied by high mortality [12].
Thus, pending further study, some experts suggest that severely malnourished children receive
fluid resuscitation with careful reassessment according to the WHO guidelines for children with
shock and no signs of malnutrition. (See 'Resource-limited settings' below.)
In resource-limited settings that cannot provide advanced airway and circulatory support, bolus
administration of albumin or normal saline may be associated with increased mortality for
children with signs of shock and severe febrile illness but without dehydration or hemorrhage.
(See "Septic shock: Rapid recognition and initial resuscitation in children", section on 'Resourc e limited settings'.)
Penetrating torso wounds Limited evidence suggests that aggressive fluid resuscitation in
patients with uncontrolled hemorrhage caused by penetrating injuries may disrupt thrombus
formation and enhance bleeding. Delayed fluid resuscitation with controlled hypotension may
be beneficial for selected patients with penetrating injuries (eg, gunshot or stab wounds) to the
torso when rapid access to emergency surgery with control of the bleeding source is possible.

However, limited evidence supports this approach and the decision to implement delayed
hypotension should be made jointly with the trauma surgeon. (See "Initial evaluation and
management of shock in adult trauma", section on 'Delayed fluid resuscitation/controlled
hypotension'.)
Resource-limited settings We suggest that children in resource-limited settings with signs of
shock receive fluid resuscitation according to the 2016 emergency triage assessment and treatment
(ETAT) guidelines developed by the World Health Organization (WHO) (table 3). This guidance also
includes, recommendations for fluid administration for children with severe anemia and for those with
severe malnutrition [19].
In addition, we recommend that children in resource-limited settings who have severe febrile illness
without dehydration or hemorrhage and with normal blood pressures not receive boluses of isotonic
fluid. In a randomized trial of bolus fluid therapy versus no bolus in such patients, administration of
20 to 40 mL/kg of isotonic crystalloid solution or albumin was associated with significantly increased
mortality. (See "Septic shock: Rapid recognition and initial resus citation in children", section on
'Resource-limited settings'.)
Children in resource-limited settings are frequently malnourished, severely anemic, and, depending
upon the region, may have a high prevalence of Falciparum malaria. Furthermore, many of these
resource-limited settings do not have critical care capability with respect to monitoring, mechanical
ventilation, and administration of vasopressors [19]. Thus, fluid administration should be tailored to
the specific cause of shock and based upon whether severe anemia, severe malnutrition, or malaria
is clinically suspected. Children receiving intravenous fluid therapy warrant frequent reevaluation of
their condition with modification of fluid therapy based upon clinical response.
Oral rehydration for children with severe malnutrition and the treatment of children with dengue virus
hemorrhagic fever are discussed in greater detail separately. (See "Severe malnutrition in children in
resource-limited countries: Treatment", section on 'Rehydration' and "Prevention and treatment of
dengue virus infection", section on 'Treatment of shock'.)
Choice of fluid Fluid therapy for children with shock should begin with isotonic crystalloid, such
as normal saline or Lactated Ringers solution, as supported by the following evidence:
Randomized trials and meta-analyses have failed to consistently demonstrate a differenc e
between colloid and crystalloid for the treatment of shock in adults. (See "Treatment of
hypovolemia (dehydration) in children", section on 'Crystalloid versus colloid' and "Treatment of
severe hypovolemia or hypovolemic shock in adults", section on 'Colloid versus crystalloid'.)
For children, randomized trials comparing colloid with crystalloid for hypotensive newborns
and for children with dengue shock syndrome have not demonstrated a difference between the
solutions [20-23].
Colloid solutions are more expensive and patients may develop adverse reactions to them.

Many patients in shock are hyperglycemic. Although identification and treatment of

hypoglycemia is very important, the rapid infusion and large amounts of bolus fluids to treat
shock necessitate exclusion of glucose from the resuscitation fluids.
Pharmacologic therapy Vasoactive agents may be useful for children with shock (other than
hypovolemic shock) who have not improved with initial fluid resuscitation. These agents have effects
on myocardial contractility, heart rate, and vasculature that can improve cardiac output (table 4).
Initiation of vasoactive agents prior to or in place of adequately fluid resuscitating the patien t,
regardless of the etiology of shock, may lead to end-organ ischemia. Furthermore, these agents
should be avoided in children with hypovolemic shock. (See "Use of vasopressors and inotropes".)
Drugs

that

are

typically used

during

the

initial

management

include dopamine, epinephrine, norepinephrine, dobutamine,

and

of

children

with

phosphodiesterase

shock
enzyme

inhibitors. The choice of agent depends on the pathophysiologic parameters that must be manipulated
[24].
The effect of dopamine is dose-dependent. At low doses, it stimulates the heart and improves
renal blood flow. At higher doses, it causes vasoconstriction and increases systemic vascular
resistance (SVR). In most situations, dopamine should be used first when vasoactive infusions
are required to treat shock that has not responded to fluid administration.
Epinephrine stimulates the heart and is a potent vasoconstrictor. It also relaxes bronchial
smooth muscle. It is typically used for patients with anaphylaxis or those who do not respond
to dopamine, particularly those with septic shock and increased SVR (cold shock) [2].
Like epinephrine, norepinephrine stimulates

the

heart

and

causes

vasoconstriction.

Vasoconstrictive effects are usually greater than the effects on contractility and heart rate. It can
be used for children who do not respond to dopamine and is preferred over epinephrine by some
experts for those patients with sepsis and decreased SVR (warm shock) [ 2].
Dobutamine increases myocardial contractility and heart rate. It also decreases systemic
vascular resistance, which can cause hypotension. It is useful for patients with decreased
myocardial function who are normotensive.
Phosphodiesterase

enzyme inhibitors

(ie, milrinone and

inamrinone)

improve

cardiac

contractility and reduce afterload. They may be used to treat cardiogenic shock [ 2,3].
Evidence for goal-directed therapy in children The following observational evidence supports
the elements of a goal-directed approach (including physiologic targets, fluid administration, and
pharmacologic therapy) for the initial management of hypovolemic and septic shock in children
(algorithm 2). These studies, when combined with clinical experience and an understanding of the
pathophysiology of shock, suggest that many children with shock benefit from early, aggressive
treatment targeted to improvement in physiologic indicators that are reliable and easy to evaluat e
[1,2,25]:
An observational

study of 1422 children with signs of shock (abnormal capillary refill,

tachycardia, and/or hypotension) who were transferred from a community hospital setting to a
tertiary care pediatric facility found that early reversal of shock in the community hospital and

use

of

Pediatric

Advanced

Life Support/Advanced Pediatric

Life

Support (PALS/APLS) interventions were associated with a decrease in mortality and morbidity
(permanent neurologic dysfunction) regardless of underlying etiology (eg, trauma, sepsis) [26]:
When adjusted for severity of illness, trauma status (trauma versus no trauma), and
treating facility, early reversal of shock was associated with a 57 percent reduction in the
odds of mortality and functional morbidity (odds ratio [OR]: 0.4; 95% CI: 0.3-0.7). Death
occurred in 16 percent (163 of 996 patients) without early shock reversal versus 5 percent
(26 of 514 patients) with early shock reversal.
When adjusted for severity of illness, trauma status (trauma versus no trauma), and
treating facility, use of PALS/APLS interventions were associated with a 40 percent
decrease in the odds of mortality and morbidity (OR: 0.6; 95% CI: 0.4-0.9). Death occurred
in 15 percent of children not receiving PALS/APLS intervention (142 of 946 patients)
versus 9 percent of children receiving PALS/APLSintervention (49 of 564 patients).
In an observational study of 136 children with septic shock, mortality was 6 percent (3 of 53
patients) in those who were not in shock on admission to a pediatric intensive care unit versus
19 percent (21 of 83 patients) in those with shock on arrival who did not have shock revers ed
during emergency department care or transport (p = 0.02) [27]. Mean transfer time ranged from
6 to 14 hours and was not different between the two groups. Fluid and vasopressor management
followed the 2002 American College of Critical Care Medicine/Pediatric Advanced Life Support
consensus guidelines in only 38 percent of these children with persistent shock.
Institution of timely goal-directed interventions by a mobile intensive care team, including early
and aggressive bolus colloid administration, endotracheal intubation and mechanical ventilation,
and vasoactive therapy in conjunction with regionalization of care for 331 children with
meningococcemia in the United Kingdom was associated with a decrease in the case fatality
rate from 23 to 2 percent over five years (annual reduction in the odds of death 0.41, 95% CI:
0.27-0.62) [28].
The use of goal-directed therapy has been associated with reduced mortality in children with
severe sepsis [2]. As an example, in one institution, the mortality rate from purpura and severe
sepsis decreased from approximately 20 to 1 percent [29]. Similarly, in the United States, death
from severe sepsis was estimated as 4 percent (2 percent in healthy children and 8 percent in
children with prior chronic illness) in 2003 compared with 9 percent in 1999 [30,31].
Trials of protocol-driven therapy for the treatment of severe sepsis and septic s hock in adults have
had variable results with the largest trials finding no mortality benefit for early goal -directed therapy.
No similar trials comparing the clinical outcomes of goal-directed therapy for septic shock in children
have been performed. However, these findings in adults may reflect a higher quality of care in the
control group relative to older studies which made the potential mortality benefit of goal -direct ed
therapy difficult to prove (see "Evaluation and management of suspected sepsis and septic shock in
adults", section on 'Protocol-directed therapy'). Given the varied presentation of severe sepsis and
septic shock in children (especially around the ranges of normal parameters for blood pressure and
heart rate), there has been less standardization of treatment in the initial management of these

patients. This lack of consistent care supports the benefits of early goal -directed therapy in this
population as a way to standardize the approach and ensure prompt therapy.
GOAL-DIRECTED APPROACH Successful management of children with shock requires the rapid
initiation of aggressive treatment. A goal-directed approach can generally be applied to most patients
who present with shock, independent of the underlying cause (algorithm 2). However, during this
initial stabilization, clues to the exact etiology of shock must also be sought to best direct subsequent
therapy and quickly identify patients who may be harmed by or not respond to this approach.
(See 'Risks' above.)
We suggest using a goal-directed approach for children who present with shock and are receiving
care in a facility with critical care capability as follows:
Rapid assessment should quickly determine the presence and presumptive type of shock.
Initial management of hypovolemic, distributive, and cardiogenic shock should focus on fluid
resuscitation with isotonic crystalloid solution appropriate to the type of shock and specific
pharmacologic therapies, as indicated, once the etiology of shock is identified. (See 'Fluid
administration' above.)
Interventions must be administered in a rapid sequence, with evaluation of physiologic
indicators before and after each intervention. The ideal timeline for the initial management of
shock in children is uncertain and may be unachievable in clinical practice. However, clinicians
should work rapidly to reverse shock utilizing all resources at their disposal.
Once physiologic goals have been achieved, indicating that perfusion is improved, the patient
should continue to receive supportive treatment and careful monitoring. Achieving a normal
blood pressure is essential for the patient who has hypotensive shock.
For children with compensated shock and normal blood pressures, therapeutic endpoints based
upon noninvasive indicators are reasonable targets, but they may be unreliable. Skin perfusion
can be influenced by room temperature, mental status may be abnormal as the result of a drug
ingestion or central nervous system infection, and accurate measurement of urine output
requires bladder catheterization.
If obstructive shock is present, it requires emergent recognition and treatment of the underlying
cause (eg, tension pneumo- or hemothorax, cardiac tamponade, congenital heart disease with
closure of the ductus arteriosus, or pulmonary embolism). If shock is due to a cardiac
arrhythmia, such as supraventricular tachycardia, then treatments to restore normal sinus
rhythm are essential initial steps (algorithm 3). (See "Initial evaluation of shock in children",
section on 'Rapid assessment' and "Pediatric advanced life support (PALS)", section on 'Heart
rate and rhythm'.)
The following algorithm for initiating and reevaluating therapy once shock is recognized has been
adapted from consensus recommendations for the management of septic shock in children which
were based primarily upon evidence extrapolated from adult studies (algorithm 2) [2,32]. Although
the specific time sequence is not usually achievable in practice in the emergency department, it
provides a point of reference that reminds clinicians of the urgency of the patient's condition:

Within the initial 5 to 15 minutes of therapy, the following actions should commence:
Vascular or intraosseous access should be established. Ideally, two access sites capable
of large volume infusion should be obtained. (See "Vascular (venous) access for pediatric
resuscitation

and

other

pediatric

emergencies",

section

on

'Peripheral

access' and "Intraosseous infusion", section on 'Techniques'.)

Rapid measurement of blood glucose should be obtained and treatment of hypoglycemia
initiated.
Trauma patients warrant prompt evaluation by a trauma surgeon to determine the need
for operative intervention. (See 'Additional management decisions' below.)
Life-threatening obstructive causes of shock should be identified and the treatment
initiated for the underlying cause (eg, pericardiocentesis

for cardiac tamponade,

anticoagulation and thrombectomy for pulmonary embolus, chest tube thoracostomy or

needle thoracentesis for pneumothorax, or prostaglandin E1 for ductal dependent
congenital

heart

disease). (See 'Life-threatening

conditions' below and 'Obstructive

shock' below.)
Isotonic crystalloid infusion should be started. Rapid infusion of 20 mL/kg over 5 minutes
should be performed in children who are hypotensive and without signs of cardiogenic or
obstructive shock.
Patients with compensated shock should also receive 20 mL/kg over 5 to 20 minutes as
long as there are no signs of cardiogenic or obstructive shock, diabetic ketoacidosis (DKA),
or other conditions that may worsen with fluid administration. (See 'Risks' above.)
For children with signs of cardiogenic shock who may be hypovolemic, fluid should be
given cautiously (5 to 10 mL/kg over 10 to 20 minutes).
Children

with

DKA

should

receive

careful

fluid

resuscitation

(one

bolus

of

10 mL/kg infused over one hour). (See 'Fluid administration'above and 'Risks' above.)
Children

with

signs

of

anaphylaxis

intramuscular epinephrine, diphenhydramine,

should

also

receive

and hydrocortisone (table

5).

(See 'Distributive shock' below.)

Heart rate and pulse oximetry should be continuously monitored and blood pressure
should be frequently accessed.
Other diagnostic studies (ie, CBC, electrolytes, serum or blood lactate, cultures, and type
and cross match) should be obtained as indicated by clinical assessment. (See "Initial
evaluation of shock in children", section on 'Ancillary studies'.)
After the initial fluid bolus, the following physiologic indicators (with goals in parentheses )
should be evaluated and repeatedly assessed during treatment:
Blood pressure (systolic pressure at least fifth percentile for age: 60 mmHg <1 month of
age, 70 mmHg + [2 x age in years] in children 1 month to 10 years of age, 90 mmHg in
children 10 years of age or older)
Quality of central and peripheral pulses (strong, distal pulses equal to central pulses)
Skin perfusion (warm, with capillary refill <2 seconds)
Mental status (normal mental status)

Urine output (1 mL/kg per hour, once effective circulating volume is restored)
Within 15 to 30 minutes of presentation, the following should be performed, if possible:
Abnormalities in calcium, and electrolyte measurements should be identified and
treatment

initiated.

(See "Overview

of

the

treatment

of

hyponatremia

in

adults" and "Treatment and prevention of hyperkalemia in adults", section on 'Patients with
a hyperkalemic emergency'and "Clinical manifestations and treatment of hypokalemia in
adults", section on 'Treatment' and "Treatment of hypocalcemia", section on 'Therapeut ic
approach'.)
Appropriate antibiotics should be administered to children who may be in septic shock.
(See 'Distributive

shock' below

and "Septic

shock: Rapid

recognition

and

initial

resuscitation in children", section on 'Initial antimicrobial therapy'.)

Children, other than those with obstructive shock, cardiogenic shock or DKA, who have
not improved should continue to receive isotonic crystalloid in 20 mL/kg boluses to a total
of 60 mL/kg over the first 30 minutes of treatment. (See 'Cardiogenic

shock' below

and "Treatment and complications of diabetic ketoacidosis in children", s ection on

'Dehydration'.)
Vasoactive drug therapy may be initiated in children with possible cardiogenic shock who
have not responded to fluid and to children with signs of septic shock who have not
responded to 60 mL/kg or more of isotonic fluid boluses. (See 'Cardiogenic shock' below
and "Use of vasopressors and inotropes".)
Patients should be evaluated for physiologic indicators of peripheral perfusion and signs
of fluid overload (decreased oxygenation, rales, gallop rhythm, hepatomegaly) before and
after each bolus.
Children who have not improved after 30 to 60 minutes should be evaluated for other causes
of shock. Consultation with pediatric critical care specialists and in victims of trauma, trauma
surgeons with pediatric expertise should be arranged. Additional therapies may be provided, as
indicated:
For children with hypovolemic shock, reassess the estimated fluid losses, continue fluid
replacement, and evaluate the need for colloid or blood transfusion. (See 'Hypovolemic
shock' below.)
For children with septic shock unresponsive to fluid, initiate vasoactive drug therapy and
evaluate the need for corticosteroid therapy. (See 'Distributive shock' below.)
Patients with fluid and/or catecholamine-resistant shock should be admitted to an intensive
care unit where additional monitoring of more precise physiologic indicators (ie, central venous
pressure and central venous oxygen saturation) can be performed. (See 'Monitoring'below
and 'Disposition' below.)
Children noted to have elevations in serum lactate at the onset of resuscitation, may benefit
from serial lactate measurements. Data in adults suggest that patients with persistent elevation
in serum lactate (lactate levels remaining within 10 percent of initial value) have a significantly
higher mortality [33].
ADDITIONAL MANAGEMENT DECISIONS

Airway management Children with signs of shock should receive supplemental oxygen. Early
positive pressure ventilation and intubation should be performed in patients with airway compromise
or impending respiratory failure [24]. These interventions can maximize oxygenation, decrease the
work of breathing, and may redistribute blood flow from respiratory muscles to more vital organs. Of
note, patients with some forms of obstructive shock (eg, tension pneumothorax) may have worsening
of their condition with positive pressure ventilation. The clinician should be alert to the possible
presence of obstructive shock and rapidly perform appropriate decompression maneuvers. (See 'Lifethreatening conditions'below.)
Intubation should be performed using a rapid sequence technique (table 6). This approach requires
that

vascular

access already

be

in place.

(See "Rapid

sequence

intubation

(RSI)

in

children" and 'Vascular access' below.)

It is important to choose agents that do not worsen cardiovascular status. Etomidate is a reasonable
choice in many children with shock, other than septic shock, because it typically does not compromise
hemodynamic stability. However, limited, low quality evidence in children suggests that etomidate
may adversely affect outcome in patients with septic shock who already have some degree of
adrenocortical suppression, such as those with severe sepsis.
We suggest the following approach in children with shock (see "Rapid sequence intubation (RSI) in
children", section on 'Etomidate' and "Rapid sequence intubation (RSI) in children", section on
'Ketamine'):
Ketamine, if available and not contraindicated, is preferable to sedate a child in septic shock.
(See "Septic shock: Rapid recognition and initial resuscitation in children", section on 'Airway
and breathing'.)
Etomidate is a reasonable sedative choice for children with hypovolemic and cardiogenic
shock.
Etomidate should not be used routinely in children with septic shock but may be appropriat e
if ketamine is otherwise contraindicated or unavailable. If etomidate is used, there is a potential
for adrenal suppression. The emergency clinician should inform the physician assuming care in
the intensive care unit that etomidate has been used and should avoid repeated bolus doses or
etomidate infusion to maintain sedation after intubation. (See "Septic shock: Rapid recognition
and initial resuscitation in children", section on 'Airway and breathing'.)
The use of corticosteroids for the treatment of septic shock in general is reviewed elsewhere.
(See "Glucocorticoid therapy in septic shock".)
Vascular access Vascular access must be quickly obtained as soon as circulatory compromise
is identified. Peripheral intravenous access should be attempted initially. Intraosseous cannulation
should be considered if rapid intravenous access cannot be secured, particularly for children who are
hypotensive. Central venous access is warranted in children with fluid refractory septic shock to assist
in guiding goal-directed therapy. (See 'Early goal-directed therapy' above and "Vascular (venous )
access for pediatric resuscitation and other pediatric

emergencies",

approach' and "Intraosseous infusion", section on 'Indications'.)

section on 'General

Life-threatening conditions Life-threatening conditions that warrant prompt intervention and can
be associated with shock include:
Angioedema with upper airway obstruction Children with upper airway obstruction from
anaphylaxis should receive epinephrine (table 5). Intubation or a surgical airway may be
necessary for patients with complete upper airway obstruction or with no response to
epinephrine. (See "Emergency evaluation of acute upper airway obstruction in children", section
on 'Algorithmic approach' and "The difficult pediatric airway", section on 'Approach to the failed
airway'.)
Tension pneumo- or hemothorax Tension pneumo- or hemothorax typically presents with
severe respiratory distress, asymmetric breath sounds, and poor perfusion and must be
promptly decompressed. (See "Prehospital care of the adult trauma patient", section on 'Needle
chest decompression' and "Placement and management of thoracostomy tubes".)
Cardiac tamponade Patients with respiratory distress, poor perfusion, muffled heart tones,
pulsus paradoxus, hepatomegaly, and/ordistended neck veins may have obstructive shock from
cardiac tamponade. Fluid must be drained as quickly as possible, preferably in the operating
room. (See "Emergency pericardiocentesis", section on 'Technique overview'.)
Ductal dependent congenital heart defects Infants under 28 days of age with a high
clinical suspicion for ductal-dependent congenital heart defects should receive prostaglandin E1
(also known as alprostadil). (See "Approach to the ill-appearing infant (younger than 90 days of
age)", section on 'Initial stabilization'.)
Pulmonary embolism Treatment for massive pulmonary embolism consists of supportive
care, antithrombotic therapy (unless otherwise contraindicated, as with patients who have had
recent surgery), and, in selected patients, thromboembolectomy. (See "Diagnosis and treatment
of venous thrombosis and thromboembolism in infants and children", section on 'Treatment
recommendations' and "Overview of the treatment, prognosis, and follow-up of acute pulmonary
embolism in adults", section on 'Embolectomy'.)
Arrhythmia Poor perfusion as a result of brady- or tachyarrhythmias requires immediate
medical attention as follows:
Supraventricular tachycardia or ventricular tachycardia with poor perfusion should be
treated with synchronized cardioversion (table 7). (See "Management and evaluation of
wide QRS complex tachycardia in children", section on 'Unstable patient'.)
Children with bradycardia who are not hypoxic should receive epinephrine (or atropine if
increased vagal tone or primary AV block is suspected) and may require cardiac
compressions (algorithm 4). (See "Pediatric advanced life support (PALS)", section on
'Bradycardia algorithm'.)
SPECIFIC MANAGEMENT DECISIONS Whenever clinical features suggest a cause of shock,
specific therapy should be initiated. (See "Initial evaluation of shock in children", section on 'Clinical
classification of shock'.)

Hypovolemic shock Intravascular fluid loss (whether from hemorrhage, vomiting, diarrhea,
osmotic diuresis, or capillary leak) is the principal feature of hypovolemic shock. (See "Initial
evaluation of shock in children", section on 'Evaluation'.)
The management of hypovolemic shock focuses on fluid replacement and preventing ongoing fluid
loss. Vasoactive infusions will not improve perfusion.
For hypovolemic shock, most children should receive 20 mL/kg per bolus, repeated as needed. Each
bolus should be infused over 5 to 10 minutes. Rapid infusion of fluids should be performed with
caution in children with severe malnutrition. (See 'Resource-limited settings' above.)
Considerations for children who have not improved after receiving a total of 60 mL/kg over 30 to 60
minutes include:
The amount of fluid loss may have been underestimated (as with burn injury) or there may be
significant ongoing fluid loss (ie, from hemorrhage with blunt abdominal trauma or capillary leak
with bowel obstruction).
Other conditions may be causing or contributing to shock (ie, a child with multiple trauma who
has a spinal cord injury).
Although controversial, colloid is a reasonable option for patients with hypoalbuminemia
(albumin <3 g/dL) or hyperchloremic metabolic acidosis who have not improved after initial
therapy with at least 60 mL/kg of crystalloid solutions [2,3]. However,

hydroxethylstarch

solutions may be harmful and should be avoided. (See "Septic shock: Rapid recognition and
initial resuscitation in children", section on 'Intravenous fluid therapy'.)
Patients with hemorrhagic shock who have not improved should receive blood and require
definitive treatment for the cause of hemorrhage [2,3]. Delayed fluid resuscitation for traumatic
hemorrhagic is not recommended for children. (See "Trauma management: Approach to the
unstable child", section on 'Fluid resuscitation'.)
Hypovolemic shock is uncommon in children with diabetic ketoacidosis (DKA). Patients in DKA whose
perfusion does not improve with 10 mL/kgof isotonic fluid should be evaluated for other causes of
shock. (See "Treatment and complications of diabetic ketoacidosis in children", section on
'Dehydration'.)
Distributive shock Distributive shock is notable for a marked decrease in systemic vascular
resistance. Thus, vasopressors are frequently employed along with fluid therapy, depending upon the
underlying etiology as follows:
Septic shock Management according to the American Critical Care Medicine guidelines for
neonates and children with septic shock is suggested (algorithm 5). Clinical manifestations,
rapid recognition, resuscitation, and initial management after resuscitation for pediatric septic
shock are discussed in detail separately:
(See "Systemic inflammatory

response syndrome (SIRS) and sepsis in children:

Definitions, epidemiology, clinical manifestations, and diagnosis" .)

(See "Septic shock: Rapid recognition and initial resuscitation in children" .)

(See "Septic shock: Ongoing management after resuscitation in children" .)
Anaphylactic shock A history of allergies and/or the presence of stridor, wheezing,
urticaria, or facial edema suggest anaphylaxis. Children with possible anaphylaxis should
receive

intramuscular epinephrine,

intravenous

or

intramuscular diphenhydramine,

and

steroids, in addition to rapid infusions of normal saline. Wheezing should be treated with
nebulized albuterol. Patients with cardiovascular collapse or those that respond poorly to
intramuscular epinephrine may require epinephrine intravenously (table 5 and table 8 and table
9). (See 'Goal-directed approach' above and "Anaphylaxis: Emergency treatment", section on
'Immediate management'.)
Neurogenic shock Neurogenic shock refers to hypotension, usually with bradycardia,
attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular
resistance. Patients with traumatic spinal cord injury may also suffer from hemodynamic shock
related to blood loss and other complications. An adequate blood pressure is believed to be
critical in maintaining adequate perfusion to the injured spinal cord and thereby limiting
secondary ischemic injury. Appropriate mean arterial pressure for age should be maintained
using intravenous fluids, transfusion, and pharmacologic vasopressors as needed. Bradycardia
caused by cervical spinal cord or high thoracic spinal cord disruption may require external
pacing or administration of atropine. (See "Acute traumatic spinal cord injury", section on
'Cardiovascular complications'.)
Cardiogenic

shock A

history

of

heart

disease,

an

abnormal

cardiac

examination, and/or worsening clinical condition with fluid resuscitation are suggestive of cardiogenic
shock. Additional findings include tachycardia out of proportion to fever or respiratory distress,
cyanosis unresponsive to oxygen, raised jugular venous pulsations, and absent femoral pulses.
Cardiogenic shock is less common than other forms of shock in children. Early consultation with a
pediatric cardiologist or intensivist is recommended. (See "Initial evaluation of shock in children",
section on 'Clinical classification of shock'.)
Management issues include the following:
Cardiogenic shock (as from myocarditis or a toxic ingestion) should be considered for any child
without a readily apparent cause for shock whose condition worsens with fluid therapy (table
10). (See "Clinical manifestations and diagnosis of myocarditis in children", sec tion on 'Clinical
manifestations'.)
Some children with poor cardiac function may also be volume depleted. Fluid should be
administered slowly and in boluses of 5 to 10 mL/kg.
Treatment with dobutamine or phosphodiesterase enzyme inhibitors can improve myocardial
contractility and reduce systemic vascular resistance (afterload). (See "Use of vasopressors and
inotropes", section on 'Dobutamine'.)
Cardiac arrhythmias (eg, supraventricular or ventricular tachycardia) should be addressed
prior to fluid resuscitation (algorithm 3).

Obstructive shock Causes of obstructive shock (eg, tension pneumothorax, cardiac tamponade,
hemothorax, pulmonary embolism, or ductal-dependent congenital heart defects) require specific
interventions to relieve the obstruction to blood flow. (See 'Life-threatening conditions' above.)
MONITORING Effective management of children with shock requires frequent adjustment of
therapeutic interventions based upon continuous hemodynamic monitoring and assessment of end
organ perfusion (brain, kidneys, and skin).
Monitoring should include continuous noninvasive measurement of heart rate and pulse oximetry with
frequent measurement of blood pressure. In addition to these parameters, the following clinical
features should also be observed before and after each fluid bolus (see 'Physiologic indicators and
target goals' above):
Quality of central and peripheral pulses
Skin perfusion (as indicated by temperature and capillary refill)
Mental status
Auscultation of lung and heart sounds
Palpation of liver edge (to identify hepatomegaly as a sign of heart failure)
More aggressive monitoring may be necessary for children who do not improve with fluid
resuscitation. (See 'Goal-directed approach' above.)
Interventions to consider include:
A urinary catheter should be placed to monitor urine output.
Children receiving vasoactive infusions should generally have arterial pressure monitoring
after initial resuscitation. Placement of intraarterial catheters may occur in the emergenc y
department or intensive care unit, depending upon resources. (See "Arterial puncture and
cannulation in children", section on 'Arterial cannulation'.)
Children with fluid and catecholamine-resistant shock should be expeditiously transferred to
intensive care units where central venous pressure (CVP) and central venous oxygen saturation
(ScvO2) can be monitored. CVP is an indication of preload. A measurement of <8 mmHg
suggests that fluid resuscitation has been inadequate.
ScvO2 measurements provide information regarding oxygen supply and consumption at the
tissue level as an indication of perfusion. Experts recommend a target ScvO 2 of >70 percent as
an indication of adequate perfusion [2]. In adults, lactate clearance is considered a reasonable
alternative to measurement of ScvO 2, but data in children are limited. (See "Evaluation and
management of suspected sepsis and septic shock in adults", section on 'Assess perfusion'.)
DISPOSITION Children with shock whose symptoms resolve with treatment should be admitted to
the hospital for observation. The cause of shock may persist (as with an infant with severe diarrhea),
may reoccur (as with a biphasic anaphylactic reaction [34,35]), or may not be apparent.

Children who have not improved with initial management and those whose conditions may worsen
(ie, with septic or cardiogenic shock) should be admitted to an intensive care unit. Early consultation
with a pediatric intensivist is suggested. Patients with hemorrhagic shock from trauma should be
evaluated by a surgeon as quickly as possible.
PITFALLS The management of children with shock is challenging. Some pitfalls include:
Failure to recognize nonspecific signs of compensated shock (ie, unexplained tachycardia,
abnormal mental status, or poor skin perfusion)
Inadequate monitoring of response to treatment
Inappropriate volume for fluid resuscitation (usually too little for children with sepsis or
hypovolemic shock, but possibly too much for those with cardiogenic shock)
Failure to reconsider possible causes of shock for children who are getting worse or not
improving
Failure to recognize and treat obstructive shock
SUMMARY AND RECOMMENDATIONS
Shock is a dynamic and unstable pathophysiologic state characterized by inadequate tissue
perfusion that must be identified promptly. Aggressive treatment within the first few hours after
presentation can prevent the invariable progression and poor outcome that characterize the
natural clinical course of shock. (See 'Definitions' above.)
Patients with obstructive shock (eg, tension pneumo- or hemothorax, cardiac tamponade,
ductal dependent congenital heart defects, or pulmonary embolus) require specific interventions
performed

emergently

to relieve

the obstruction to blood flow. (See 'Life-threatening

conditions' above.)
For the initial management of children with shock, other than obstructive shock, who are cared
for in a setting with critical care capability, we suggest early goal-directed therapy (algorithm 2)
(Grade 2C). Physiologic indicators that should be targeted include central and peripheral
pulses, skin perfusion, mental status, blood pressure, and urine output (once effective
circulating volume is restored). Physiologic indicators should be frequently assessed.
(See 'Goal-directed approach' above and 'Monitoring' above.)
The etiology and degree of shock determines the volume and rate of initial fluid resuscitation
(table 1) (see 'Fluid administration' above):
We recommend that children with hypotensive hypovolemic or distributive shock (as
from gastrointestinal losses, traumatic hemorrhage, sepsis, or anaphylaxis), receive
20 mL/kg per bolus of isotonic crystalloid, such as normal saline or Ringers Lactate
solution, infused over 5 to 10 minutes and repeated, as needed, up to four times in patients
without

improvement

and no signs

of

fluid

overload

(Grade

1C).

(See 'Fluid

administration' above and 'Evidence for goal-directed therapy in children' above.)

We suggest that children with compensated hypovolemic or distributive shock, other
than those with diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone
secretion, severe malnutrition, or, in resource-limited settings, severe febrile illness without

dehydration or hemorrhage, receive 20 mL/kg per bolus of isotonic crystalloid, such as

normal saline or Ringers Lactate solution over 5 to 20 minutes (Grade 2C). Patients should
be closely monitored during fluid administration. (See 'Fluid administration' above
and 'Risks' above.)
For suspected cardiogenic shock, children who are also hypovolemic should receive a
smaller isotonic crystalloid fluid bolus of 5 to 10 mL/kg, infused over 10 to 20 minutes. This
approach decreases the likelihood of exacerbating heart failure.
Children with diabetic ketoacidosis (DKA) should receive careful fluid resuscitation (one
bolus of 10 mL/kg infused over one hour) in order to avoid cerebral edema, a rare
complication of DKA. (See "Treatment and complications of diabetic ketoacidosis in
children", section on 'Cerebral edema'.)
We suggest that children with signs of shock cared for in resource-limited settings that do
not have critical care capability with respect to monitoring, mechanical ventilation, and
administration of vasopressors receive fluid resuscitation according to the emergenc y
triage assessment and treatment guidelines developed by the World Health Organization
(WHO) (Grade 2C). We recommend that children in resource-limited settings who have
severe febrile illnesses without dehydration or hemorrhage and with normal blood
pressures notreceive

boluses of isotonic fluid (Grade 1B). (See 'Resource-limit ed

settings' above.)
We recommend that children with shock receive isotonic crystalloid rather than colloid as the
initial fluid therapy (Grade 1B). (See 'Choice of fluid' above.)
Additional care includes establishing a secure airway and assessing for and treating lifethreatening conditions (ie, upper airway obstruction, tension pneumothorax, cardiac tamponade,
and unstable tachycardia). (See 'Additional management decisions' above.)
In the absence of severe malnutrition, fluid resuscitation and preventing ongoing fluid loss are
the treatments for hypovolemic shock. Children who have not improved following the rapid
infusion of 60 mL/kg of crystalloid should be carefully reevaluated. We suggest that those with
nontraumatic hypovolemic shock who have capillary leak or hypoalbuminemia and do not
respond to 60 mL/kg of crystalloid receive colloid therapy or blood products (Grade 2C).
Children with hemorrhagic shock who do not respond to 60 mL/kg of crystalloid should receive
blood. (See 'Hypovolemic shock' above.)
For neonates and children with septic shock, additional management according to the
American College

of Critical

Care Medicine guidelines

is suggested (algorithm

5).

(See 'Distributive shock' above and "Septic shock: Rapid recognition and initial resuscitation in
children", section on 'Early goal-directed therapy'.)
Children

with

anaphylaxis

intramuscular epinephrine, diphenhydramine,

require
and

prompt
steroids

(table

treatment
5).

with

(See 'Distributive

shock' above and "Anaphylaxis: Emergency treatment".)

All children who have been treated for shock should be admitted to the hospital. Those who
do not improve with initial treatment should be admitted to an intensive care unit.
(See 'Disposition' above.)
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REFERENCES