Paediatric Shock Management
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Direct answer
Paediatric shock is inadequate tissue perfusion that children compensate for well, so blood pressure can stay normal until late. Hypovolaemia is the commonest type in children, arising from diarrhoea, haemorrhage or burns, while septic shock is the commonest distributive type. Early shock is recognised by tachycardia, prolonged capillary refill and cool peripheries, and it is treated with isotonic crystalloid boluses of about 20 mL/kg, reassessed after each one.
What you must remember
- Definition: inadequate tissue perfusion, in which oxygen delivery falls short of the tissues' demand.
- Compensated shock: normal blood pressure with tachycardia, vasoconstriction, prolonged capillary refill and cool peripheries.
- Decompensated shock: hypotension appears late, with altered consciousness and weak pulses.
- Hypovolaemic shock: the commonest type, from diarrhoea with vomiting, haemorrhage or burns.
- Septic shock: typically warm early, with bounding pulses and vasodilatation, which may become cold as it progresses.
- Obstructive shock: tension pneumothorax and pericardial tamponade need immediate decompression or drainage.
- Fluid bolus: 20 mL/kg isotonic crystalloid over 5 to 10 minutes, with reassessment after every bolus.
A stepwise resuscitation pathway
Shock is managed as a time-critical sequence, with fluid, cause and escalation addressed in parallel. Early recognition matters more than the blood pressure reading.
- Recognise early shock: look for tachycardia, capillary refill longer than about two seconds, cool peripheries and abnormal behaviour, since blood pressure may still be normal.
- Secure access and oxygen: give high-flow oxygen, establish intravenous or intraosseous access, and check blood glucose.
- Give a bolus: infuse 20 mL/kg of isotonic crystalloid over 5 to 10 minutes, and reassess heart rate, perfusion, breathing and liver size afterwards.
- Identify and treat the cause: consider haemorrhage, sepsis, dehydration or obstruction, and give antibiotics within the first hour when sepsis is suspected.
- Escalate to vasoactive drugs: if shock persists after adequate fluid, start adrenaline or noradrenaline and transfer the child to intensive care.
- Review continuously: watch for fluid overload, with crackles, a large liver or falling oxygen saturation, since over-resuscitation is harmful.
Where the exam tries to catch you
Questions on this topic usually test early signs, fluid volumes and the dengue exception.
- Trap: reassuring a tachycardic child because blood pressure is normal Correct: children compensate, so normal blood pressure does not exclude shock, and tachycardia and capillary refill are the early signs.
- Trap: waiting for hypotension before giving fluids Correct: hypotension is a late sign, so bolus treatment starts at the compensated stage.
- Trap: giving unlimited fluid to every shocked child Correct: each bolus is reassessed, because excess fluid can cause pulmonary oedema in heart failure or dengue.
- Trap: treating dengue shock like septic shock with routine large boluses Correct: dengue shock is driven by plasma leakage, so fluid is given in carefully titrated boluses.
Frequently asked questions
Why does blood pressure stay normal in early paediatric shock?
Blood pressure stays normal in early paediatric shock because children compensate with tachycardia and peripheral vasoconstriction. Hypotension appears only when compensation fails, so tachycardia, prolonged capillary refill and cool peripheries are the earlier signs of shock.
What is the initial fluid bolus in paediatric shock?
The initial fluid bolus in paediatric shock is 20 mL/kg of isotonic crystalloid given over 5 to 10 minutes. The response is reassessed after each bolus, and further boluses are given only while the child remains in shock without signs of fluid overload.
What are the common causes of hypovolaemic shock in children?
The common causes of hypovolaemic shock in children include severe diarrhoea with vomiting, haemorrhage and burns. Dehydration from gastroenteritis is a frequent cause in Indian paediatric practice, and fluid replacement is the mainstay of management.
How does dengue shock differ from septic shock in children?
Dengue shock differs from septic shock because it results from plasma leakage rather than systemic vasodilatation. Fluid is therefore given in carefully titrated boluses with close monitoring, since excessive fluid can worsen pulmonary oedema.