Paediatric Shock
Lesson Objectives
By the end of this lesson, learners should be able to:
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Define shock and describe its pathophysiology.
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Identify the types and causes of shock in children.
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Recognize the clinical signs of shock.
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Outline the stepwise management of shock according to Zambian Paediatric Protocol.
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Calculate and administer appropriate fluid resuscitation and inotropes safely.
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Implement ongoing monitoring and reassessment principles.
Description
Shock is an acute process characterized by the body’s inability to meet tissue oxygen demands for normal aerobic metabolism, leading to cellular dysfunction and organ failure.
Types and Causes of Shock
| Type | Mechanism | Possible Causes |
|---|---|---|
| Hypovolemic | Decreased preload due to volume loss | Blood loss, acute diarrhoeal disease, vomiting, burns, nephrotic syndrome |
| Cardiogenic | Cardiac pump failure due to poor cardiac function | Congenital heart disease, cardiomyopathies, ischemia, arrhythmias |
| Distributive | Abnormalities of venous and arterial tone | Anaphylaxis, spinal cord/brainstem injury, certain drugs |
| Septic | Multiple forms of shock secondary to infection | Bacterial, fungal, or viral infections |
| Obstructive | Decreased cardiac output due to block to heart flow or chamber restriction | Tension pneumothorax, cardiac tamponade, pulmonary embolism, critical coarctation of the aorta |
Investigations
Investigations should be guided by clinical assessment and suspected cause.
| Category | Tests |
|---|---|
| Baseline | FBC/DC, CRP/ESR |
| Infectious | Urine or blood cultures |
| Renal function | Urea, creatinine, electrolytes |
| Cardiac assessment | ECG, echocardiogram (ECHO) |
| Imaging | Chest X-ray (CXR) |
Clinical Recognition of Shock
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Cold extremities
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Capillary refill time > 3 seconds
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Weak and rapid pulse
Initial Management (ABCDE Approach)
| Step | Action |
|---|---|
| A – Airway | Stabilize and maintain airway; use adjuncts (chin lift, jaw thrust, guedel airway). If severe angioedema → suspect anaphylaxis. |
| B – Breathing | Provide high-flow oxygen (15 L/min via mask or 2 L/min nasal catheter). |
| C – Circulation | Establish 2 large-bore IV lines; if difficult, use intraosseous route. Assess for malnutrition and severe anaemia. |
| D – Disability | Assess consciousness (AVPU scale) and check random blood sugar; treat hypoglycaemia as needed. |
| E – Exposure | Check temperature, rashes; weigh the child (or estimate using: <1 yr = (Age in months + 9)/2; >1 yr = (Age + 4) × 2). |
Fluid Resuscitation
| Step | Action |
|---|---|
| Initial bolus | 10–20 mL/kg crystalloid (Ringer’s Lactate or 0.9% Normal Saline) over 5–10 min |
| Reassessment | After each bolus; if respiratory distress develops, stop fluids but maintain line |
| Refractory shock | If no response after 40 mL/kg total → prepare for referral/intubation and start inotropes with monitoring |
⚠️ Avoid fluid bolus in cardiogenic shock unless clear hypovolaemia is present.
Antibiotic Therapy
All children with shock not clearly due to trauma or simple diarrhoea should receive broad-spectrum antibiotics within the first hour per local protocol (for probable sepsis).
Further Management
| Aspect | Action |
|---|---|
| Temperature | Maintain normothermia (36.5–37.5 °C), keep warm, give antipyretics if febrile. |
| Glucose | If blood sugar < 3.0 mmol/L → Give 10% dextrose 5 mL/kg IV and recheck after 15 min. |
| Monitoring | Frequent reassessment, consider type of shock and adjust treatment. |
| Blood transfusion | Avoid unless severe anaemia present. |
| Escalation | Liaise with senior doctors; consider inotropes as first-line if fluids fail. |
Inotrope Administration (Use central line if possible)
| Drug | Dose Range (mcg/kg/min) | Preparation Formula | Infusion Rate Example |
|---|---|---|---|
| Dopamine | 3–20 | Body weight (kg) × 6 = mg drug in 100 mL IV fluid | 1 mL/h = 1 mcg/kg/min → 10 mL/h = 10 mcg/kg/min |
| Dobutamine | 1–20 | Same as dopamine | Same as above |
| Epinephrine | 0.01–1.0 | Body weight (kg) × 0.6 = mg drug in 100 mL IV fluid | 1 mL/h = 0.1 mcg/kg/min → 3 mL/h = 0.3 mcg/kg/min |
| Norepinephrine | 0.01–1.0 | Same as epinephrine | Same as above |
| Milrinone | As per protocol | Same preparation principle | As per clinical judgment |
Key Summary
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Shock is a life-threatening emergency requiring rapid identification and management.
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Follow ABCDE systematically.
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10–20 mL/kg crystalloid boluses with reassessment.
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Avoid overhydration in cardiogenic shock.
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Start inotropes if not responding after 40 mL/kg fluids.
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Antibiotics within 1 hour if infection suspected.
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Frequent reassessment is essential.