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Christine A. Zawistowski, MD
Introduction
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Time 05 min
The timeline for treatment starts in the rst 5 min
with the recognition of shock and should ideally be
prior to the onset of hypotension. Clinical signs of
shock include an alteration of body temperature with
hypothermia or hyperthermia, alteration in mental
status, and peripheral vasodilation (warm shock) or
TABLE 1. Algorithm for time sensitive goal-directed, stepwise management of shock in infants and children2
Time
Recognition
05 min
Intervention
1. Recognize shock: decreased mental status and perfusion
2. Begin high-ow oxygen
3. Establish IV/IO access
1. Push boluses of 20 ml/kg isotonic saline or colloid 460 ml/kg until perfusion
improves or rales or hepatomegaly develop
2. Correct hypoglycemia
3. Correct hypocalcemia
4. Start antibiotics
1.
2.
3.
4.
ECMO
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Agent
Clinical effect
Dose
Dopamine
Epinephrine
Norepinephrine
Milrinone
Vasopressin
Hydrocortisone
Calcium chloride
Calcium gluconate
Dextrose
0.032 mU/kg/min
250 mg/kg/d
10 mg/kg
100 mg/kg
24 mL/kg; 12.5% dextrose if o2 months,
24 mL/kg; 25% dextrose if 42 months
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288
Cold Shock
Cold shock is a consequence of poor cardiac output and
is evidenced by poor peripheral perfusion with cool
extremities, delayed capillary rell, and diminished or
absent peripheral pulses. Low cardiac output (cold shock)
has been shown to be associated with mortality in
pediatric patients.19,20 Vasoactive agents suitable for the
treatment of cold shock include dopamine and epinephrine administered into the central circulation.21 The dosing
range for dopamine should fall within 59 mcg/kg/min;
at this dose, it works as an inotrope to improve contractility.22 In instances when dopamine is ineffective,
epinephrine in a dosing range of 0.050.3 mcg/kg/min
should be used; in this dosing range, it acts predominantly as a -adrenergic agonist with a resulting increase
in heart rate and stroke volume. It should be noted that
epinephrine stimulates gluconeogenesis and glycogenolysis and inhibits the action of insulin, leading to an
increase in blood glucose. Epinephrine also promotes
increased delivery of lactate to the liver (to be used as a
substrate for glucose production), with a resulting
increase in blood lactate concentration.
Warm Shock
Warm shock is caused by low systemic venous
resistance. Patients in this state appear overly well
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