Recognizing signs of shock in pediatric patients can be tricky
ED nurses must pay close attention to symptoms of shock in children, stresses Mary Fran Hazinski, RN, MSN, FAAN, clinical specialist in the division of trauma at Vanderbilt University and Children's Hospital in Nashville, TN. "The signs of shock can be very subtle in pediatric patients," she says. Here are tips to consider when assessing and treating children in shock:
Start with the ABCs. If the child's airway and oxygenation are adequate, move on to circulation. "The heart rate should always be appropriate for the child's clinical condition-tachycardia is usually much more appropriate than a normal cardia or bradycardia," says Hazinski. "You also need to evaluate peripheral perfusion and color, the child's responsiveness, and signs of organ profusion such as urine output."
Continuously evaluate the child's response to therapy. "If the child is not becoming more alert and improving, then you need to be worried that there is something else going on with the child," says Hazinski. "The child should be getting better as you treat-if not, there is something else wrong."
Don't overestimate the significance of blood pressure. Hypotension can be an early sign of shock in adults, but not for children, says Hazinski. "The child is much more heart-rate dependent than the adult is," she notes. "A child may well be in shock and still have a normal blood pressure."
More reliable signs are altered mental status and poor perfusion, says Richard A. Orr, MD, FAAP, associate director of the pediatric ICU and medical director of pediatric transport at Children's Hospital of Pittsburgh (PA). "During PALS classes when we give presentations on shock, we're still hearing 'The patient's blood pressure is OK so we didn't give our 20 cc/kg of fluid,'" he notes. "It still hasn't sunk in for a lot of people that blood pressure is not an accurate gauge."
Give patients enough fluid. Don't be afraid to give enough volume. A study showed that survivors of septic shock who were treated in the prehospital environment had received greater than 40 cc/kg of fluid in their first hour of presentation, he notes.1 "Pulmonary edema was not associated with the amount of fluid given, which is a common fear," says Orr.
"You want to give enough fluid but not too much-a minimum of 40 cc/kg for the first hour," Orr recommends. "Once we give between 40-100 cc/kg of fluid and don't see the patient responding in terms of improved perfusion and blood pressure, we start low dose inotropic agents such as epinephrine."
Don't delay intubation when appropriate. "If the patient has altered mental status (a Glasgow Coma Scale score of 10 or less), or if the patient is unable to maintain oxygen saturation above 92% on 15 LPM of 100% 02 or 100% non-rebreathing mask, then I would intubate the patient," says Orr.
The idea is to take away the work of breathing early in the shock course, he explains. "We don't allow our patients to work hard at breathing," he adds. "Fifteen to 20% of cardiac output goes to the work of breathing-we advocate early intubation instead of waiting for blood gases to deteriorate."
Monitor fluid intake. Small amounts of fluid deficit or gain can be significant in a small child, says Hazinski. "You really have to keep track of all fluid intake the child receives, and all the fluid out," she stresses.
Listen to parents opinions. "Many times parents will seek medical attention because the child is 'not acting right.' and this can be a very reliable indicator of a serious problem," says Hazinski. "Listen carefully to what they tell you, while keeping in mind a sense of how you think the child looks," she says.
Consider other causes. It is often difficult to tell the difference between shock and other types of distress, such as pain or respiratory problems, says Hazinski. "They can also cause tachycardia or peripheral vasoconstriction, so they need to be evaluated too," she notes.
For infants presenting with shock in first month of life, it's important to rule out hypoplastic left heart syndrome. "We've seen a number of these go unrecognized," says Orr. "Signs and symptoms include tachypnea, increased work of breathing, poor perfusion, diminished or absent pulses, and a persistent metabolic acidosis that is not responding to therapy that is aimed at improving shock."
Examine the abdomen to determine whether the liver edge is palpable. "This suggests that the patient is beginning to experience right heart failure and congestion," says Orr. "Normally, the liver edge should not be palpable." The liver edge is almost always palpable for patients who are in cardiogenic shock or late in the course of septic shock, he notes. "With this physical finding, I would begin inotropic agents as part of the treatment," says Orr. "In the prehospital setting, I would begin epinephrine infusion at 0.1 mcg/kg/min and titrate to both perfusion and blood pressure. Dopamine is often ineffective in cardiogenic shock." (See following story to learn more about types of shock.)
Detect shock early. Early detection can prevent organ system failure and more complications (see sidebar for signs of shock). "We have become more successful in the treatment of shock in children, but there is no question that early detection or prevention is the best form of therapy," Hazinski emphasizes. "The child's responsiveness is an important sign, if the child fails to give good eye contact, or if a toddler fails to protest when separated from parents that is worrisome," she says.
Reference
1. Carcillo JA, Davis AI, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA 1991;266:1242.