Synopsis
Identify compensated shock before hypotension, distinguish hypovolaemic, distributive, cardiogenic and obstructive mechanisms, use fluid as a measured treatment trial, and escalate promptly to blood, antimicrobials, vasoactive support or source control when physiology does not recover.
- Recognise shock from a pattern: heart rate, central and peripheral pulses, refill, skin temperature and colour, blood pressure, consciousness and urine output.
- A child can be in compensated shock with a normal blood pressure; hypotension, bradycardia or diminished central pulses are late.
- First-line action is ABCDE, high-concentration oxygen in critical illness, monitoring, glucose and rapid IV or IO access without repeated delay.
- Classify the likely mechanism as hypovolaemic, distributive, cardiogenic or obstructive because the next treatment differs.
- For hypovolaemic or distributive shock, use a 10 mL/kg balanced isotonic crystalloid bolus where appropriate and reassess immediately.
- Reassessment includes heart rate, pulses, refill, blood pressure, consciousness, urine, breathing, crackles and liver edge; record the response and cumulative volume.
- In cardiogenic shock, fluid need is individual and a cautious 5 mL/kg trial may be used only with early cardiac and critical-care guidance.
- Haemorrhagic shock needs bleeding control, activation of the massive-haemorrhage pathway and early blood; minimise crystalloid and give tranexamic acid when indicated.
- Septic shock needs blood cultures if this causes no delay and broad-spectrum antimicrobial treatment within one hour alongside haemodynamic support.
- Consider vasoactive infusion early and no later than after three to four ineffective 10 mL/kg boluses; peripheral or IO initiation is preferable to waiting for a central line.
- Obstructive shock improves only when tension pneumothorax, tamponade or another mechanical obstruction is relieved.
- Renal, cardiac, hepatic and nutritional comorbidity changes fluid distribution and tolerance; smaller trials and earlier specialist support are safer.
Key red flags
Hypotension is a late sign in children; normal blood pressure does not exclude clinically important shock.
Bradycardia, diminished central pulses and reduced consciousness indicate decompensation rather than a reassuring fall in tachycardia.
Rising respiratory rate, crackles, falling saturation or an enlarging liver after fluid suggests overload or myocardial dysfunction.
Uncontrolled external or internal bleeding needs immediate source control and early blood, not repeated crystalloid dilution.
Muffled heart sounds, distended veins, unequal air entry or sudden deterioration during positive-pressure ventilation suggests obstructive shock requiring procedural treatment.
A non-blanching rash, fever or hypothermia, altered behaviour and poor perfusion warrants immediate sepsis management even before laboratory confirmation.
Known congenital heart disease, cardiomyopathy, renal failure or severe malnutrition changes fluid tolerance and requires smaller aliquots and expert input.
Investigation priorities
Recognise shock and measure response using several age-adjusted variables.
Detect hypoglycaemia, ventilation failure, acidosis and impaired perfusion rapidly.
Management branches
Multiple age-adjusted perfusion variables are persistently abnormal.
- Activate senior and critical-care help and start monitored ABCDE.
- Give high-concentration oxygen for critical illness and obtain IV or prompt IO access.
- Check glucose and gas and send cause-directed samples without delaying treatment.
- Name the likely shock mechanism and choose the first cause-specific action.