History:

 

• Blood
• Fluid loss (vomiting/diarrhea/fever)
• Infection
• Congenital defects
• Birth complications
• Medications
• Allergic reaction
• History of poor oral intake

 

Significant Findings:

 

• Restlessness
• Confusion
• Weakness
• Dizziness
• Weak, rapid pulse
• Pale, cool, clammy skin
• Delayed capillary refill
• Decreased blood pressure

 

Differential:

 

• Shock
• Trauma
• Infection
• Dehydration
• Congenital heart disease
• Medication/toxin
• Allergic reaction

 

• Use age appropriate heart rate and blood pressure levels

 

 Treatment:

 

• Oxygen

 

• 12-Lead EKG

 

• Obtain BGL

 

• Initiate IV

 

Hypotension due to cardiogenic shock (tachycardia) ?

 

 

• • Normal Saline 20 mL/kg IV; max 60 mL/kg or 1,000 mL

 

• • OLMC: Push Dose Epi: 10 mcg (1 ml) q 3-5 mins

 

See appropriate cardiac protocol

 

Non-trauma Non-cardiac (no bradycardia) ?

 

• Normal Saline 20 mL/kg IV; max 60 mL/kg or 1,000 mL

 

Improvement ?

 

• Yes

 

• • Notify receiving facility or contact Medical Control

 

• No

 

• • OLMC: Request additional fluid (Medical Control)

 

Hypotension due to bradycardia ?

 

• See Bradycardia Protocol

 

PEARLS:

 

• Pediatric
  • 1 day to less than age 12, or
  • less than 55 kg in ages 12-18.
• Use Handtevy for drug dosages.
• Consider all possible causes of shock and treat per appropriate protocol.
• Consider possible allergic reaction or early anaphylaxis.
• Decreasing heart rate and hypotension occur late in children and are signs of imminent cardiac arrest.
• Work of breathing is a better indicator of oxygenation and ventilation than rate and lung sounds

• Most maternal medications pass through breast milk to the infant. Consider Naloxone (Narcan) 0.1 mg/kg IV/IO; max 2 mg.

• If the patient has a history of cardiac disease (e.g., prematurity), chronic lung disease, or renal disease, limit Normal Saline bolus to 10 mL/kg.

 

• Age based SBP hypotension

 

• • less than 1 year:
    • less than 70
  • 1-10 years:
    • less than 70 + (2 x age)
  • greater than 11:
    • less than 90 + (2 x age)

 

Appearance

 

• Often the first clue to a problem
• Tone
• Interactiveness
• Consolability
• Look/gaze (eye contact)
• Speech/cry

 

Skin Circulation

 

• Reflects overall adequacy of perfusion

 

 Abnormal audible breath sounds

 

• Stridor - upper airway obstruction
• Wheezing - partially blocked small airways
• Grunting - lower airway (pneumonia)
• Retractions - suprasternal, intercostal, or subcostal
• Nasal flaring
• Positioning

 

• Abnormal appearance + Poor circulation

• • = SHOCK

 

• Abnormal appearance + Change in work of breathing

• • = RESPIRATORY FAILURE

 

• Normal appearance + Change in work of breathing

• • = RESPIRATORY DISTRESS