Initial shock management in children in settings with access to ICU care

ICU: intensive care unit; HR: heart rate; BP: blood pressure; HFNC: high-flow oxygen by nasal cannula; NIV: noninvasive ventilation; IV: intravenous; IO: intraosseous; US: ultrasound; ECHO: echocardiography; PT: prothrombin time; INR: international normalized ratio; PTT partial thromboplastin time; ECG: electrocardiography; e-FAST: extended focused assessment with sonography for trauma.
* A trial of HFNC or NIV, such as continuous positive airway pressure ventilation or bi-level positive airway pressure ventilation, may avoid the need for endotracheal intubation in selected patients. Patients with hemodynamic instability should receive appropriate interventions to treat shock prior to or during intubation. Refer to UpToDate content on HFNC, NIV, and rapid sequence intubation in children.
¶ Ancillary studies are determined by patient presentation and suspected type or types of shock present. Other laboratory and ancillary studies may also be indicated based upon the suspected underlying condition that is causing shock.
Δ Fluid volume should be calculated based upon ideal body weight (eg, 50^th percentile for age).
◊ When performed by trained and experienced physicians, bedside ECHO can provide rapid evidence of myocardial dysfunction, including dysfunction due to obstructive shock.
§ Patients with signs of fluid overload who continue to receive fluid boluses warrant close monitoring for respiratory and cardiac failure. The clinician should have a low threshold for endotracheal intubation and mechanical ventilation to treat pulmonary edema in these patients.
¥ Suggested vasoactive therapy depends upon type of shock and clinical findings; refer to UpToDate topics and graphics on management of shock in children.