PALS Provider: Course
Recognition of Shock in Pediatric Patients
Shock occurs when oxygen delivery to tissues is insufficient to meet metabolic demands, leading to organ dysfunction and potential failure. Pediatric patients compensate well initially, but once they decompensate, deterioration is rapid. Early recognition and intervention are critical to prevent irreversible damage or cardiac arrest.
Key Goals in Pediatric Shock Management
- Identify the type of shock early based on clinical presentation.
- Initiate appropriate resuscitation (fluids, vasopressors, inotropes).
- Prevent progression to decompensated shock and cardiac arrest.
Types of Shock & Key Features
| Type of Shock | Primary Cause | Key Signs |
|---|---|---|
| Hypovolemic | Inadequate intravascular volume | Tachycardia, weak pulses, dry mucous membranes, delayed cap refill, low urine output |
| Distributive | Abnormal vasodilation & blood pooling | Bounding pulses, warm extremities (early), hypotension, altered mental status |
| Cardiogenic | Pump failure (ineffective cardiac output) | Tachycardia, cool extremities, hepatomegaly, pulmonary edema, weak pulses |
Key Differentiator: Hypovolemic and cardiogenic shock typically present with cold extremities, while distributive shock often presents with warm extremities during early phases.
Hypovolemic Shock
Definition: Caused by decreased intravascular volume, leading to inadequate preload, stroke volume, and cardiac output.
Common Causes: Dehydration, hemorrhage, burns, diabetic ketoacidosis.
Early Signs: Tachycardia, weak peripheral pulses, cool extremities, delayed cap refill, low urine output, dry mucous membranes.
Late Signs: Hypotension, altered mental status, anuria.
Treatment:
- 20 mL/kg IV bolus of isotonic fluids over 5–10 minutes; repeat as needed up to 60 mL/kg.
- Treat underlying cause (bleeding, dehydration, DKA).
- Monitor for signs of fluid overload if response is poor.
Distributive Shock
Definition: Due to vasodilation and blood pooling, leading to poor perfusion despite normal or increased cardiac output.
Common Causes: Sepsis, anaphylaxis, neurogenic shock.
Early Signs (Warm Shock): Tachycardia, bounding pulses, warm extremities, wide pulse pressure.
Late Signs (Cold Shock): Cool extremities, weak pulses, hypotension, altered mental status.
Treatment:
- Aggressive fluid resuscitation (20 mL/kg IV boluses).
- Start vasopressors: epinephrine (anaphylaxis), norepinephrine or epinephrine (sepsis).
- Treat the underlying cause (antibiotics for sepsis, epinephrine for anaphylaxis).
Cardiogenic Shock
Definition: Due to pump failure from intrinsic cardiac dysfunction.
Common Causes: Congenital heart defects, myocarditis, arrhythmias, cardiomyopathy.
Signs: Severe tachycardia, weak pulses, hepatomegaly, pulmonary edema, jugular venous distension.
Treatment:
- Avoid fluid boluses if pulmonary edema is present.
- Use inotropes (epinephrine, dopamine, dobutamine) to improve cardiac output.
- Treat specific cause (arrhythmias → adenosine or cardioversion; ductal lesions → prostaglandin E1).
Quick Reference: Differentiating Shock Types
| Feature | Hypovolemic | Distributive | Cardiogenic |
|---|---|---|---|
| Common Causes | Dehydration, hemorrhage | Sepsis, anaphylaxis, neurogenic | CHD, myocarditis, arrhythmias |
| Heart Rate | Tachycardia | Tachycardia | Severe tachycardia or bradycardia |
| Pulses | Weak | Bounding (early), weak (late) | Weak |
| Capillary Refill | Delayed | Rapid (early), delayed (late) | Delayed |
| Skin Temp | Cold | Warm (early), cold (late) | Cold |
| Lung Exam | Clear | Clear | Crackles |
| Fluid Response | Improves | Improves (early) | Worsens |
Summary: Why Early Shock Recognition Matters
- Tachycardia is often the first and most sensitive indicator of shock.
- Hypotension is a late and dangerous sign—treat shock before it progresses.
- Fluid boluses are appropriate for hypovolemic and distributive shock, but can be harmful in cardiogenic shock.
- Early differentiation of shock type guides effective treatment and improves outcomes.
Takeaway: Pediatric shock progresses rapidly—early recognition and timely intervention are essential to preventing cardiac arrest and improving survival.