QOD 12 31 09

A 6-month-old child with a two-day history of vomiting and diarrhea presents with lethargy, pallor, weak pulses, and delayed capillary refill. Which of the following should be administered?

A. Normal saline 20 mL/kg
B. Packed red blood cells 10 mL/kg
C. Fresh frozen plasma 20 mL/kg
D. Whole blood 20 mL/kg

You are unable to obtain IV access for the patient in question above. Which of the following is the next appropriate step?

A. Transfer the patient to another facility.
B. Place an intraosseous access device.
C. Discharge the patient with instructions for a clear liquid diet.
D. Attempt to place a central venous line.

Appropriate management of patients presenting in shock necessitates rapid recognition of the shock state and determination of the most plausible etiology for the shock. Certain treatment principles apply regardless of the etiology and should be instituted immediately for all patients presenting with signs of shock. Attention should first be directed toward airway and breathing. Even patients with a patent airway and spontaneous respirations may benefit from early intubation to reduce metabolic demand and assure adequate oxygenation and ventilation, especially in cases of severe or decompensated shock. All patients should be placed on supplemental oxygen, preferable by a high-flow mask.

The next management priority should be establishing vascular access. This is best accomplished through the placement of a peripheral intravenous catheter of as large a caliber as is possible for the patient's size. Every effort should be made to have at least two functioning IVs in severely ill or injured patients. The rate of flow through a catheter is proportional to the diameter and inversely proportional to the length of the catheter; therefore short, large-caliber catheters are preferred over long, central venous lines for initial resuscitation. When IV access cannot be quickly established, consideration should be given to placement of an intraosseous (IO) access device. Historically, IO access was recommended only for infants and young children. Newer devices, however, allow the IO route to be used for older children and adults. Fluid therapy should be initiated immediately after access is established. The majority of patients presenting in shock have some degree of absolute or relative intravascular volume depletion and may benefit from intravenous fluids. Early, aggressive fluid resuscitation has been shown in multiple studies to improve survival and outcomes in adult and pediatric septic shock patients. Even patients presenting with suspected cardiogenic shock may benefit from fluid resuscitation, but fluids should be given in smaller amounts and patients should be carefully monitored for signs of worsening congestive heart failure. The following sections will review the general management principles for different types of shock. Medical personnel caring for patients in shock must remember that any given patient may have a mixture of etiologies causing the shock state, and treatment must be tailored to the individual patient's presentation.

While some patients in early shock state may be successfully resuscitated in the emergency department to the point of stability for hospitalization on a regular hospital ward, most patients presenting in shock will need ongoing care in an intensive care setting. During initial resuscitation, plans should be made for transfer to an appropriate level of care.

Hypovolemic shock is the most common shock state affecting pediatric patients. Leading causes of hypovolemic shock in these patients are hemorrhage from trauma and dehydration from gastrointestinal losses (vomiting and diarrhea). All patients presenting in hypovolemic shock require rapid vascular access (IV or IO) and volume resuscitation. Initial fluid therapy should consist of a 20 mL/kg bolus of isotonic crystalloid fluid such as normal saline or Ringer's lactate. This bolus should be given as quickly as possible. If the patient's heart rate, level of consciousness, and capillary do not improve, a second bolus of 20 mL/kg should be rapidly administered. Blood should be drawn for determination of electrolyte and hemoglobin levels and for type and crossmatch of red blood cells in trauma patients. Hypoglycemia should be corrected if present. Patients presenting with severe hypovolemic shock may need 40–60 mL/kg of crystalloid for initial resuscitation. In cases of trauma, if systemic perfusion does not respond to administration of 40–60 mL/kg of crystalloid, packed red blood cells should be transfused in 10–15 mL/kg aliquots. Blood transfusion may be repeated as needed. Type-specific crossmatched blood is preferred; however, Type O blood may be used in urgent circumstances until crossmatched blood is available. Emergent surgical consultation should be arranged for patients exhibiting signs of shock after trauma, as they may require surgical exploration to identify and correct ongoing hemorrhage.

^{Answer: A (first question)}

^{Answer: B (second question)}