Shock

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Resuscitation is a means of stabilizing a patient who is suffering physiological dysfunction, for example, when they stop breathing or their heart stops functioning correctly. There are different types of resuscitation intended to correct different physiological disorders.

Conditions that necessitate resuscitation include cardiac arrest, lack of consciousness, septic shock, respiratory distress and failure, severe burns, and several others.

This article discusses situations when resuscitation should be performed on children, as well as the specific types of resuscitation.

Causes of shock

The most common cause of pediatric shock worldwide is hypovolemia resulting from gastroenteritis. Other frequent causes of shock in children and infants include:

• Trauma (e.g. hemorrhagic shock)
• Sepsis
• Congenital heart disease and heart failure
• Poisoning or drug toxicity
• Abnormally high/low heart rate

Types of shock

There are different types of shock, each depending on the specific physiologic abnormality behind the condition. In some cases, there can be more than one type of shock present due to concurrent physiological derangements.

Hypovolemic shock: The most common type of shock found in children, hypovolemic shock occurs when intravascular and/or extravascular fluid volume drops. This can happen due to diarrhea or hemorrhage, among other causes. The drop in fluid volume causes cardiac output to fall.

Distributive shock: Distributive shock is most often caused by sepsis and is characterized by an abnormal distribution of blood flow and decreased tissue perfusion. Although it can also lead to hypovolemia, cardia output during distributive shock is often normal or increased, rather than reduced.

Cardiogenic shock: Cardiogenic shock is characterized by pump failure in the heart and decreased cardiac output. This type of shock is more common in adults than in children. The leading cause of cardiogenic shock in children is cardiac arrhythmias (irregular heart rhythms).

Obstructive shock: Obstructive shock is associated with impaired cardiac output and occurs when blood flow is physically obstructed.

Stages of shock

There are 3 potential stages of shock one can go through if treatment is ineffective or not delivered early enough. The shock begins with an initial event that causes disturbances in tissue perfusion and can progress to organ damage or death.

Compensated shock: The first stage of shock, compensated shock, is when the body’s self-regulating mechanisms take over in order to maintain blood pressure and compensate for diminished tissue perfusion. During this stage, heart rate will increase and symptoms such as cool skin and decreased urine production may appear.

Hypotensive shock: During the second stage of shock, the body’s compensatory mechanisms become overwhelmed and blood pressure drops (hypotension). Symptoms of organ dysfunction (e.g. altered mental status) begin to appear and the condition can progress to cardiovascular collapse and cardiac arrest.

Irreversible shock: In the final stage of shock, organ damage is irreversible and death is likely. Resuscitation may be attempted, but the outcomes are poor.

Symptoms of shock in children

• Tachycardia (abnormally rapid heart rate)
• Cool, clammy skin
• Pale or mottled complexion
• Impaired mental status manifesting as listlessness, agitation, or lack of interaction with caregivers
• Coma (as shock worsens)
• Oliguria (abnormally low urine production)
• Lactic acidosis (lactic acid buildup in the bloodstream) can manifest as abdominal pain, decreased appetite, or shallow breathing
• Hypotension (abnormally low blood pressure)

Management of shock

Initial management of shock involves aggressive treatment to stabilize the patient and target the physiologic abnormalities resulting from shock. During initial stabilization, it is important to try and determine the type of shock present and its underlying causes, as this will inform further treatment methods.

There is no one way of treating shock, as it requires rapidly stabilizing the underlying issues and managing any damaging effects that arise from the condition. Methods for treating shock can include fluid resuscitation, hypoglycemia treatment, antimicrobial therapy, and administration of intramuscular epinephrine, diphenhydramine, and a glucocorticoid.