Shock in children in resource-abundant settings: Initial management

INTRODUCTION — This topic will review the initial management of children with shock. The classification of pediatric shock, initial evaluation of shock in children, management of specific types of shock as well as treatment of shock in resource-limited settings are discussed separately:

●(See "Pathophysiology and classification of shock in children".)

●(See "Initial evaluation of shock in children".)

●(See "Sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis".)

●(See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)".)

●(See "Hypovolemic shock in children in resource-abundant settings: Initial evaluation and management".)

●(See "Shock in children in resource-limited settings: Initial management".)

DEFINITIONS — Shock is a physiologic state characterized by a significant, systemic reduction in tissue perfusion that results in decreased tissue oxygen delivery and diminished removal of harmful byproducts of metabolism (eg, lactate). According to the Pediatric Advanced Life Support (PALS) course, shock is further classified into the following stages [1] (see "Pathophysiology 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 (eg, cool skin, decreased peripheral pulses, and oliguria) can be noted as perfusion becomes further compromised.

●Hypotensive shock – For patients with hypotensive shock, compensatory mechanisms are overwhelmed. The heart rate is markedly elevated, and hypotension develops. Signs and symptoms of organ dysfunction (eg, 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 often 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 type is characterized by a primary physiologic derangement (table 1) (see "Pathophysiology 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'.)

CLINICAL AND PHYSIOLOGIC TARGETS — Early goals of therapy for shock target improvement of clinical and physiologic signs. Interventions are determined by the degree of illness and response to treatment within the first few hours of care. This approach has been most strongly promoted for children with septic shock. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Resuscitation'.)

Clinical and physiologic indicators that should be targeted during therapy (with goals in parentheses) include [1]:

●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 indicator of improved perfusion in response to treatment (table 2). However, many other factors (ie, fever, drugs, hypoxia, and anxiety) influence 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'.)

The above 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. For example, capillary refill time is a valuable initial physiologic parameter that can be evaluated without the need for technology or equipment. Normal capillary refill in children is less than two seconds. Volume depletion or hypotension can delay capillary refill to more than three seconds. Arterial vasodilation in patients with warm shock can cause "flash" capillary refill (<1 second). On the other hand, the usefulness of capillary refill is limited by interobserver variability and by the effect of environmental temperature. Thus, capillary refill should not be used as the sole indicator of compromised systemic perfusion. (See "Assessment of systemic perfusion 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 [2]. When performed by trained and experienced physicians, bedside Doppler ultrasound shows promise as a noninvasive method to guide vasoactive therapy by calculating cardiac output from measurements of blood flow over the pulmonary artery or aorta [3].

In addition to the targets listed above, 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 serum or blood lactate levels has been associated with improved survival in children with sepsis. Rapid determination of blood lactate may be obtained at the bedside. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Approach'.)

EARLY RECOGNITION — There are a number of screening tools that have been studied in order to identify patients at risk for poor outcomes, mainly from septic shock. Rapid recognition of shock can facilitate timely resuscitation, which can reduce mortality. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Rapid recognition'.)

INITIAL STABILIZATION

Approach — Successful management of children with shock requires the rapid initiation of aggressive treatment. An approach that targets improvement in specific physiologic and clinical findings can generally be applied to most patients who present with shock, independent of the underlying cause. 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 'High-risk conditions' below.)

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 targeting therapy using physiologic and clinical goals including central and peripheral pulses, capillary refill time, mental status, blood pressure, and urine output (see 'Clinical and physiologic targets' above):

●Rapid assessment should quickly determine the presence and presumptive type of shock (algorithm 1). Initial management of hypovolemic, distributive, and cardiogenic shock (table 1) 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 (algorithm 2). (See 'Volume and rate' below.)

●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 depending upon patient factors and setting. 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 immediate 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'.)

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 shock recognition and treatment, the following actions should commence:

•Monitor heart rate and pulse oximetry continuously and measure blood pressure frequently.

•Establish vascular or intraosseous access. Ideally, obtain two access sites, preferably with large-gauge, short, peripheral catheters capable of large volume infusion. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies", section on 'Peripheral access' and "Intraosseous infusion", section on 'Techniques'.)

•Obtain rapid measurement of blood glucose and treat hypoglycemia as needed.

•For trauma patients, assure prompt evaluation by a trauma surgeon to determine the need for operative intervention. (See "Trauma management: Approach to the unstable child", section on 'Circulation'.)

•Identify life-threatening obstructive causes of shock and treat the underlying cause, such as (see 'Other emergency conditions' below and 'Obstructive shock' below):

-Pericardiocentesis for cardiac tamponade (see "Emergency pericardiocentesis")

-Anticoagulation and thrombectomy for pulmonary embolus (see "Venous thrombosis and thromboembolism (VTE) in children: Treatment, prevention, and outcome")

-Chest tube thoracostomy or needle thoracentesis for pneumothorax (see "Thoracostomy tubes and catheters: Indications and tube selection in adults and children")

-Prostaglandin E1 for ductal dependent congenital heart disease (see "Diagnosis and initial management of cyanotic heart disease in the newborn", section on 'Prostaglandin E1')

When used by a properly trained and experienced provider, point-of-care ultrasound (POCUS) can assist with rapid detection of cardiac tamponade [3] or pneumothorax. (See "Bedside pleural ultrasonography: Equipment, technique, and the identification of pleural effusion and pneumothorax", section on 'Evaluation for pneumothorax'.)

•In children without signs of fluid overload, isotonic crystalloid infusion should be started. Rapid infusion of 20 mL/kg over five minutes should be performed in children who are hypotensive and without findings of cardiogenic shock. POCUS may help identify patients with poor cardiac function or pulmonary edema in whom fluid administration may need to be modified.

•Patients with compensated shock should also receive 10 to 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 'High-risk conditions' below.)

•For children with signs of cardiogenic shock who may be hypovolemic, fluid should be given cautiously (lower volume and over a longer period of time [eg, 5 to 10 mL/kg over 15 to 30 minutes]).

•Children with DKA should receive careful fluid resuscitation as described separately. (See "Diabetic ketoacidosis in children: Treatment and complications", section on 'Initial volume expansion'.)

•Children with signs of anaphylaxis should also receive intramuscular epinephrine, diphenhydramine, and a glucocorticoid (eg, methylprednisolone) (table 3). (See 'Distributive shock' below.)

•Other diagnostic studies (ie, complete blood count, electrolytes, serum or blood lactate, cultures, and type and crossmatch) 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:

•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)

●Over the next 15 to 60 minutes after recognition of shock, the following actions are warranted:

•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 'Therapeutic approach'.)

•Appropriate antimicrobial therapy should be initiated for children with suspected septic shock. (See 'Distributive shock' below and "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Empiric antibiotic 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 to 60 minutes of treatment. (See 'Cardiogenic shock' below and "Diabetic ketoacidosis in children: Treatment and complications", section on 'Dehydration'.)

•Vasoactive drug therapy may be initiated in children with possible cardiogenic or neurogenic 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 60 minutes should be evaluated for other causes of shock. Consultation with pediatric critical care specialists and, in trauma patients, 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 distributive shock unresponsive to fluid and vasoactive drug therapy, 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 [CVP] and central venous oxygen saturation [ScvO₂]) can be performed. (See 'Monitoring' below and 'Disposition' below.)

●For children noted to have elevations in serum lactate at the onset of resuscitation, serial lactate measurements may help guide further treatment. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Approach'.)

Airway management — Children with signs of shock should receive supplemental oxygen to avoid hypoxemia and maximize oxygen delivery. In patients with hypoxemia despite supplemental oxygen, a trial of noninvasive ventilation, such as continuous positive airway pressure ventilation or bi-level positive airway pressure ventilation, may avoid the need for endotracheal intubation in selected patients. 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 in patients who deteriorate after positive-pressure ventilation and rapidly perform appropriate decompression maneuvers. (See 'Other emergency conditions' below.)

In patients with respiratory failure, intubation should be performed using rapid sequence intubation (RSI) (table 4). If time permits, patients with hemodynamic instability should receive appropriate interventions to manage shock prior to RSI. It is also important to choose medications that do not worsen cardiovascular status. Etomidate is a reasonable choice for sedation during RSI for children with shock, other than septic shock, because it typically does not compromise hemodynamic stability.

When performing RSI in children with septic shock, ketamine, if available and not contraindicated (ie, patients younger than three months of age or with schizophrenia), is suggested for sedation. Etomidate is not recommended unless ketamine is not available or is contraindicated by psychosis. Fentanyl in doses of 1 to 2 mcg/kg given slowly is suggested for infants younger than three months of age. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Airway and breathing'.)

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 performed 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 'Clinical and physiologic targets' above and "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies", section on 'General approach' and "Intraosseous infusion", section on 'Indications'.)

Fluid resuscitation — The type of shock (or combination of types) may not be apparent at presentation. Frequent assessment of the patient's response to fluid resuscitation often provides essential information to guide subsequent treatment.

Type of fluid — For children with shock, we suggest balanced crystalloid solutions, such as normal saline or Ringer’s lactate, rather than colloid because clinical outcomes are similar and crystalloid therapy is more widely available and less expensive:

●Randomized trials and meta-analyses have failed to consistently demonstrate a difference between colloid and crystalloid for the treatment of hypovolemic shock in adults; crystalloid solutions are generally preferred over colloid solutions. (See "Treatment of severe hypovolemia or hypovolemic shock in adults", section on 'First-line: Crystalloid solutions'.)

●For children, randomized trials comparing colloid with crystalloid for hypotensive newborns, children in resource-limited settings with either hypotensive or nonhypotensive febrile illness, and for children with dengue shock syndrome have not demonstrated a difference between the solutions [4-8].

●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.

Although normal saline is commonly used and acceptable, lactated Ringer solution is suggested by some experts for the treatment of children with septic shock. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Fluid resuscitation'.)

Volume and rate — The etiology (table 1 and algorithm 1) and degree of shock determines the volume and rate of initial fluid resuscitation:

●For children without signs of fluid overload and with hypotensive hypovolemic or distributive shock (as from gastrointestinal losses, traumatic hemorrhage, sepsis, or anaphylaxis), rapid fluid resuscitation is required and we suggest administration of isotonic crystalloid (eg, normal saline or lactated Ringer solution) in a volume of 20 mL/kg and, in patients without improvement, repeat 20 mL/kg fluid boluses as needed up to two or three times over 30 to 60 minutes titrated to clinical effect [1]. (See 'Outcomes' below.)

●We suggest that children with compensated hypovolemic or distributive shock, other than those with syndrome of inappropriate antidiuretic hormone secretion (SIADH), severe malnutrition, or, in resource-limited settings, severe febrile illness without dehydration or hemorrhage, receive 10 to 20 mL/kg per bolus of isotonic crystalloid such as normal saline or Ringer's Lactate solution over 5 to 20 minutes. These patients should be closely monitored and frequently reassessed during and after each fluid bolus during resuscitation. The presence of an enlarging liver, crackles in the lungs, or jugular venous distension should alert the provider to possible fluid overload. (See 'High-risk conditions' below.)

●For children with signs of fluid overload (eg, rales, worsening respiratory distress, new or worsening oxygen requirement, gallop rhythm, hepatomegaly, or cardiomegaly or pulmonary edema on chest radiograph) or suspected cardiogenic shock, fluid resuscitation should be administered carefully with lower fluid volume over a longer period of time (eg, 5 to 10 mL/kg infused over 15 to 30 minutes). This approach decreases the likelihood of exacerbating heart failure. Patients with signs of fluid overload who continue to receive fluid boluses warrant close monitoring for respiratory and cardiac failure. The clinician should have a low threshold for initiating vasoactive medications for persistent shock and endotracheal intubation with mechanical ventilation to treat pulmonary edema in these patients.

Excessive fluid resuscitation may be harmful for patients who are not hypovolemic or have compensated shock with certain comorbidities such as patients with (see 'High-risk conditions' below):

●Cardiogenic shock (including neonates with ductal-dependent congenital heart disease)

●Severe anemia

●Severe malnutrition

●SIADH

●Penetrating injuries to the torso

●Obstructive shock caused by tension pneumo- or hemothorax or cardiac tamponade

Limited evidence exists concerning the optimal amount and rate of fluid administration for children with shock. Several studies support the use of crystalloid solutions (ie, Ringer's lactate or normal saline) as the initial resuscitation fluid for septic shock other than obstructive shock (eg, tension pneumothorax, pericardial tamponade, or massive pulmonary embolus). (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Fluid resuscitation'.)

High-risk conditions — Aggressive fluid replacement may be harmful in patients with the following conditions:

●Cardiogenic shock – Although many children with cardiogenic shock have some degree of hypovolemia, fluid resuscitation should be omitted or administered slowly (eg, over 15 minutes or longer) and in boluses of 5 to 10 mL/kg in such patients to avoid worsening myocardial insufficiency and pulmonary edema. Clinical findings of cardiogenic shock include gallop rhythm, jugular venous distension, pulmonary rales, hepatomegaly, or cardiomegaly or pulmonary edema on chest radiograph. Bedside ultrasound by a trained and experienced physician can be a useful tool when assessing for and determining the degree of cardiogenic shock.

Neonates with ductal dependent lesions and circulatory collapse may also be hypovolemic. However, primary treatment should focus on reopening the ductus arteriosus with prostaglandin E1 (alprostadil). (See 'Outcomes' below and 'Obstructive shock' below.)

●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 [9]. 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) [10].

●Severe malnutrition – Intravenous fluid resuscitation in children with severe malnutrition and signs of shock is discussed separately. (See "Shock in children in resource-limited settings: Initial management", section on 'Fluid therapy' and "Shock in children in resource-limited settings: Initial management", section on 'Nonhemorrhagic hypovolemic shock'.)

●Syndrome of inappropriate antidiuretic hormone secretion (SIADH) – Aggressive fluid therapy in individuals with SIADH can cause cerebral edema in patients with meningitis and adult respiratory distress syndrome in patients with pneumonia as a result of fluid overload. (See "Pathophysiology and etiology of the syndrome of inappropriate antidiuretic hormone secretion (SIADH)", section on 'Etiology'.)

●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 fluid resuscitation of hypotension should be made jointly with the trauma surgeon. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Delayed fluid resuscitation/controlled hypotension'.)

●Obstructive shock – Fluid resuscitation in a patient with obstructive shock such as cardiac tamponade, pneumothorax, or pulmonary embolism does not address the primary problem and may delay definitive treatment.

Vasoactive agents — 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 5). Initiation of vasoactive agents prior to or in place of adequately fluid resuscitating the patient, 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 of children with shock include epinephrine, norepinephrine, dopamine, dobutamine, and phosphodiesterase enzyme inhibitors. The choice of agent depends on the pathophysiologic parameters that must be manipulated [11].

●Epinephrine stimulates the heart and is a potent vasoconstrictor. It also relaxes bronchial smooth muscle. It is typically used for patients with anaphylaxis and as initial treatment for patients with shock after cardiac arrest or selected patients with septic shock. (See "Anaphylaxis: Emergency treatment" and "Pediatric advanced life support (PALS)", section on 'Avoid recurrent hypotension' and "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Patients with fluid-refractory shock' and "Initial post-cardiac arrest care in children", section on 'Circulation'.)

●Like epinephrine, norepinephrine stimulates the heart and causes vasoconstriction. Vasoconstrictive effects are usually greater than the effects on contractility and heart rate, which also makes it helpful in selected children with septic shock. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Patients with fluid-refractory shock'.)

●At low doses, dopamine stimulates the heart and improves renal blood flow. At higher doses, it causes vasoconstriction and increases systemic vascular resistance. Although an acceptable medication for the treatment of septic shock, evidence suggests that epinephrine or norepinephrine may be more effective. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Patients with fluid-refractory shock'.)

●Dobutamine increases myocardial contractility and heart rate. It also decreases systemic vascular resistance, which can cause hypotension. It may be 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.

Additional recommendations for the use of vasoactive agents in children with septic shock are provided separately. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Patients with fluid-refractory shock'.)

Other emergency conditions — Several life-threatening conditions that warrant prompt intervention can present with shock as described below.

Angioedema with upper airway obstruction — Children with upper airway obstruction from anaphylaxis should receive epinephrine (table 3). 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 'Determining the cause of upper airway obstruction' and "The difficult pediatric airway for emergency medicine", 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 "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)

Cardiac tamponade — Patients with respiratory distress, poor perfusion, muffled heart tones, pulsus paradoxus, hepatomegaly, and/or distended 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'.)

Kawasaki disease and multisystem inflammatory syndrome in children (MIS-C) — For patients with Kawasaki disease (algorithm 4) and most patients who meet the case definition for MIS-C (table 6), specific therapies are suggested, as discussed separately. (See "Kawasaki disease: Initial treatment and prognosis" and "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) management and outcome".)

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 "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults", section on 'Embolectomy' and "Venous thrombosis and thromboembolism (VTE) in children: Treatment, prevention, and outcome", section on 'Approach to VTE treatment'.)

Arrhythmia — Patients with brady- or tachyarrhythmias and shock require treatment according to Pediatric Advanced Life Support (PALS) guidelines (algorithm 3 and algorithm 5). (See "Pediatric advanced life support (PALS)".)

Adrenal insufficiency — Patients at risk for adrenal insufficiency due to purpura fulminans, recent or chronic treatment with corticosteroids, hypothalamic or pituitary abnormalities, or other causes of congenital or acquired adrenal insufficiency should be treated with stress-dose hydrocortisone early in the course of resuscitation (intravenous hydrocortisone 50 to 100 mg/m²/day or approximately 2 to 4 mg/kg/day, intermittent or continuous infusion, maximum dose 200 mg/day). (See "Treatment of adrenal insufficiency in children".)

Causes and diagnosis of adrenal insufficiency in children are discussed separately. (See "Clinical manifestations and diagnosis of adrenal insufficiency in children" and "Causes of primary adrenal insufficiency in children" and "Causes of central adrenal insufficiency in children".)

FURTHER MANAGEMENT BY TYPE OF SHOCK — 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 and should be avoided.

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. (See "Hypovolemic shock in children in resource-abundant settings: Initial evaluation and management", section on 'Fluid resuscitation'.)

Children with severe malnutrition may warrant adjustment of fluid volume and rate. (See "Shock in children in resource-limited settings: Initial management", section on 'Nonhemorrhagic hypovolemic shock'.)

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. However, hydroxyethyl starch solutions may be harmful and should be avoided. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Fluid resuscitation'.)

●Patients with hemorrhagic shock who have not improved should receive blood and require definitive treatment for the cause of hemorrhage. 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). Fluid management in patients with DKA is discussed separately. (See "Diabetic ketoacidosis in children: Treatment and complications", 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 – We endorse management of septic shock according to the 2020 Surviving Sepsis Campaign International Guidelines for the management of septic shock and sepsis-associated organ dysfunction in children (algorithm 6). Clinical manifestations, rapid recognition, resuscitation, and initial management after resuscitation for pediatric septic shock are discussed in detail separately:

•(See "Sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis".)

•(See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)".)

•(See "Septic shock in children in resource-abundant settings: Ongoing management after resuscitation".)

●Toxic shock syndrome – In addition to treatment as for septic shock, patients with clinical findings suggesting toxic shock syndrome warrant specific therapy according to the likely pathogen:

•Staphylococcus aureus – Surgical debridement (as needed), removal of infected foreign bodies, and clindamycin along with broad spectrum antibiotics. (See "Staphylococcal toxic shock syndrome".)

•Group A Streptococcus – Surgical debridement, clindamycin along with broad spectrum antibiotics, and intravenous immunoglobulin (IVIG). (See "Invasive group A streptococcal infection and toxic shock syndrome: Treatment and prevention".)

●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 who respond poorly to intramuscular epinephrine may require epinephrine intravenously (table 3 and table 7 and table 8). (See 'Initial stabilization' 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:

●Cardiac arrhythmias (eg, supraventricular or ventricular tachycardia or symptomatic bradycardia) should be addressed prior to fluid resuscitation (algorithm 3 and algorithm 5).

●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. (See "Clinical manifestations and diagnosis of myocarditis in children", section on 'Clinical manifestations' and "Beta blocker poisoning" and "Calcium channel blocker poisoning" and "Digitalis (cardiac glycoside) poisoning".)

●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'.)

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 'Other emergency 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 'Clinical and physiologic targets' above):

●Quality of central and peripheral pulses

●Capillary refill time

●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 'Initial stabilization' above.)

Key measurements include:

●Urine output – A urinary catheter should be placed to monitor urine output.

●Arterial blood pressure – Children receiving vasoactive infusions should generally have arterial pressure monitoring after initial resuscitation. Placement of intra-arterial catheters may occur in the emergency department or intensive care unit, depending upon resources. (See "Arterial puncture and cannulation in children", section on 'Arterial cannulation'.)

●Central venous pressure (CVP) and oxygen saturation (ScvO₂) 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. (See "Septic shock in children in resource-abundant settings: Ongoing management after resuscitation", section on 'Ongoing and invasive monitoring'.)

ScvO₂ measurements provide information regarding oxygen supply and consumption at the tissue level as an indication of perfusion. For children with septic shock, guidelines recommend a target ScvO₂ of >70 percent as an indication of adequate perfusion. (See "Septic shock in children in resource-abundant settings: Ongoing management after resuscitation", section on 'Ongoing and invasive monitoring'.)

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 [12,13]), 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 due to pneumo- or hemothorax, cardiac tamponade, or pulmonary embolism

OUTCOMES — The following observational evidence supports the presented approach (including physiologic targets, fluid administration, and pharmacologic therapy) for the initial management of undifferentiated 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 and clinical findings that are reliable and easy to evaluate [1,14,15]:

●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) [16]:

•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/APLS intervention (49 of 564 patients).

For children with septic shock, institutional institution of resuscitation protocols and guidelines improve adherence to best practices, decrease time to therapy, and improve outcomes. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Institutional guidelines and protocols'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Shock in children".)

SUMMARY AND RECOMMENDATIONS

●Approach – The management of shock in children requires rapid patient assessment to quickly determine the presence and presumptive type of shock (algorithm 1). Our approach to shock is provided in the algorithm (algorithm 2). (See 'Approach' above and "Initial evaluation of shock in children".)

●Airway management – Provide supplemental oxygen to children with signs of shock and prepare for respiratory failure that requires noninvasive or mechanical ventilation. (See 'Airway management' above.)

Perform rapid sequence intubation (RSI) in patients with respiratory failure who fail or are not candidates for noninvasive ventilation (eg, cannot protect their airway. Provide interventions to treat shock prior to or during RSI. Use medications that are safe for patients with hemodynamic instability such as ketamine or etomidate (table 4). (See 'Airway management' above.)

●Vascular access – Rapidly obtain vascular access as soon as circulatory compromise is identified. Initially attempt peripheral intravenous access. If peripheral access cannot be readily obtained, perform intraosseous cannulation. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies", section on 'General approach' and "Intraosseous infusion", section on 'Indications'.)

●Obstructive shock – Patients with obstructive shock require specific time-sensitive interventions performed immediately to restore circulation:

•Tension pneumo- or hemothorax: Chest tube placement (needle thoracostomy may temporarily relieve tension pneumothorax)

•Cardiac tamponade: Pericardiocentesis

•Ductal dependent congenital heart defects: Prostaglandin E1 infusion

•Pulmonary embolus: Antithrombotic therapy and, in selected patients, thromboembolectomy

Patients with arrhythmias and shock require treatment according to Pediatric Advanced Life Support (PALS) guidelines (algorithm 3 and algorithm 5). (See 'Other emergency conditions' above.)

●Clinical targets – For the initial management of children with shock, other than obstructive shock, we recommend targeting therapy using physiologic and clinical goals (ie, pulses, capillary refill, mental status, systolic blood pressure, and urine output). (See 'Clinical and physiologic targets' above.):

Tachycardia (table 2) and elevation of serum or blood lactate (>4 mmol/L) are also important indicators of poor hemodynamic status that warrant reassessment during resuscitation. (See 'Initial stabilization' above and 'Monitoring' above.)

●Fluid resuscitation – We suggest that children with shock receive isotonic crystalloid (eg, normal saline or lactated Ringer solution) rather than colloid as the initial fluid therapy because clinical outcomes are similar and crystalloid therapy is more widely available and less expensive (Grade 2B). (See 'Type of fluid' above.)

For patients with hypovolemic, distributive, or cardiogenic shock, the type (table 1) and degree of shock determines the volume and rate of initial fluid resuscitation (see 'Volume and rate' above and 'Outcomes' above):

•Hypotensive shock – Children without signs of fluid overload and with hypotensive hypovolemic or distributive shock (as from gastrointestinal losses, traumatic hemorrhage, sepsis, or anaphylaxis) require emergency fluid resuscitation. For these patients, we suggest a volume of 20 mL/kg over 5 to 10 minutes and repeated, as needed, up to three times over 30 to 60 minutes (Grade 2C).

Avoid rapid fluid administration in patients with (see 'High-risk conditions' above):

-Cardiogenic shock (including neonates with ductal-dependent congenital heart disease)

-Severe anemia

-Severe malnutrition

-Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

-Penetrating injuries to the torso

-Obstructive shock caused by tension pneumo- or hemothorax or cardiac tamponade

•Compensated shock – For previously healthy children in settings with critical care capability who have compensated hypovolemic or distributive shock, we suggest administration of isotonic crystalloid in a volume of 10 to 20 mL/kg over 5 to 20 minutes (Grade 2C).

•Suspected cardiogenic shock or signs of fluid overload – For children with suspected cardiogenic shock or signs of fluid overload, fluid resuscitation should be administered carefully with lower isotonic crystalloid fluid volume over a longer period of time (eg, 5 to 10 mL/kg, infused over 15 to 30 minutes). This approach decreases the likelihood of exacerbating heart failure.

Fluid resuscitation for children with diabetic ketoacidosis (DKA) and children who severe febrile illnesses without dehydration or hemorrhage are described separately. (See "Diabetic ketoacidosis in children: Treatment and complications", section on 'Cerebral injury'.)

●Fluid-refractory shock – Re-evaluate children who have not improved following the rapid infusion of 60 mL/kg of crystalloid for signs of distributive or cardiogenic shock. For children with nontraumatic hypovolemic shock who have capillary leak or hypoalbuminemia, we suggest colloid therapy or blood products (Grade 2C). Children with hemorrhagic shock who do not respond to 40 to 60 mL/kg of crystalloid should receive blood and may warrant surgery or angiographic embolization to stop bleeding. (See 'Hypovolemic shock' above and "Trauma management: Approach to the unstable child".)

●Vasoactive agents – Avoid vasoactive agents in children with hypovolemic shock. Vasoactive agents are warranted for children with distributive or cardiogenic shock who have not improved with initial fluid resuscitation. The choice of agent depends upon the specific etiology (see 'Vasoactive agents' above):

•Anaphylaxis or shock after cardiac arrest – Continuous infusion of epinephrine (table 7 and table 8) (see "Anaphylaxis: Emergency treatment" and "Pediatric advanced life support (PALS)", section on 'Avoid recurrent hypotension' and "Initial post-cardiac arrest care in children", section on 'Circulation')

•Septic shock – Continuous infusion of epinephrine or norepinephrine (algorithm 6) (see "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Patients with fluid-refractory shock')

•Cardiogenic shock – Continuous infusion of dobutamine (normotensive patients) or phosphodiesterase inhibitors (eg, milrinone and inamrinone)

●Further management – Whenever clinical features suggest a cause of shock, additional therapy should be provided as described above and separately. (See 'Other emergency conditions' above and 'Further management by type of shock' above.)