Shock (severely impaired circulation)

Shock is defined as an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. There are many causes:

Hypovolaemic e.g. haemorrhage, gastroenteritis, burns
Distributive e.g. septicaemia, anaphylaxis
Cardiogenic e.g. heart failure, cardiomyopathy
Obstructive e.g. tension pneumothorax, cardiac tamponade
Dissociative e.g. profound anaemia

Shock is an emergency which needs to be identified and treated urgently.

Important points in history

History of trauma or burns
Profuse diarrhoea and vomiting
Inability to drink
Abdominal pain
Fever
Ingestion of drug or food
Known cardiac condition
Pallor

Important points in examination

A child is in shock if s/he has all three of:

Cold hands

Capillary refill time >3 seconds

Fast weak pulse

Bleeding
Burns
Fever
Urticaria, oral swelling, wheeze
Hepatomegaly, oedema, fine crackles, cardiac murmur, muffled heart sounds
Respiratory distress, tracheal deviation, distended neck veins, reduced air entry
Pallor
Petechiae

Management

Ensure adequate Airway and Breathing
Give Oxygen
If bleeding apply pressure
Keep warm
Establish IV or IO access
Check for evidence of severe malnutrition

Shock in Malnutrition

Further Treatment of the underlying cause of shock

All children in shock or treated for shock should be initially admitted to an HDU.

Causes of Shock Specific management in addition management described above.

Hypovolaemic Haemorrhage

Pressure to site of bleeding

Involve surgeons early

Urgent cross match

Gastroenteritis Once shock treated manage as per acute gastroenteritis protocol

Intussusception, volvulus, peritonitis Contact Surgeons

Burns

If shock within few hours of burn consider other cause for shock

Give fluids according to extent of burn following burn protocol

Distributive Septicaemia IV antibiotics

Anaphylaxis IM Adrenaline, See Anaphylaxis protocol

Spinal Cord Injury Contact orthopaedic surgeons

Cardiogenic Heart Failure, Cardiomyopathy, Valvular disease

Give resuscitation fluid cautiously

Discuss with senior

Duct-dependent congenital Heart disease

Unlikely to survive in this setting

Involve Umodzi

Obstructive Tension pneumothorax

Needle thoracocentesis

Then chest drain

Haemothorax Chest drain

Flail chest

Consider advanced ventilatory support

Call surgeons

Cardiac Tamponade Emergency needle pericardiocentesis

Dissociative Profound Anaemia Urgent blood transfusion

	Causes of Shock	Specific management in addition management described above.
Hypovolaemic	Haemorrhage	Pressure to site of bleeding Involve surgeons early Urgent cross match
Gastroenteritis	Once shock treated manage as per acute gastroenteritis protocol
Intussusception, volvulus, peritonitis	Contact Surgeons
Burns	If shock within few hours of burn consider other cause for shock Give fluids according to extent of burn following burn protocol
Distributive	Septicaemia	IV antibiotics
Anaphylaxis	IM Adrenaline, See Anaphylaxis protocol
Spinal Cord Injury	Contact orthopaedic surgeons
Cardiogenic	Heart Failure, Cardiomyopathy, Valvular disease	Give resuscitation fluid cautiously Discuss with senior
Duct-dependent congenital Heart disease	Unlikely to survive in this setting Involve Umodzi
Obstructive	Tension pneumothorax	Needle thoracocentesis Then chest drain
Haemothorax	Chest drain
Flail chest	Consider advanced ventilatory support Call surgeons
Cardiac Tamponade	Emergency needle pericardiocentesis
Dissociative	Profound Anaemia	Urgent blood transfusion

NB: Formula to calculate fluids in burns

Initial 24 hours:
Ringer’s lactate - normale maintenance fluids plus 1 ml/kg x % burn
Next 24 hours:
Normale maintenance fluids (Ringers lactate plus 5 % dextrose)
Discontinue drip after 48 hourse if well resuscitated
Contact burns unit if in any doubt

Measure urine output for 48 hours
Admit to burns unit once stabilized