EMS World Expo Quick Take: Improving outcomes for pediatric shock patients
Know the difference between septic shock and cardiogenic shock and how to treat both in the field
Early identification and treatment of pediatric shock in the prehospital setting can greatly improve patient outcomes, but understanding the different types of non-traumatic shock, and the differences between pediatric and adult shock, is crucial for proper management of the condition.
New Orleans EMS Deputy Medical Director Meg Marino, MD, FAAP, who is also a pediatric emergency medicine physician, presented an overview of prehospital management of pediatric septic and cardiogenic shock at the virtual EMS World Expo 2020. Here are some key takeaways:
Memorable quotes about improving outcomes for pediatric shock patients
"Sepsis is the leading cause of death for kids worldwide. And once septic shock is present, the mortality rate can be as high as 50%."
"Studies show that all patients with septic shock who received 40 mL/kg of normal saline in the first hour survived. This piece of information is key because this helps us to know that a paramedic with a patient has all of the tools that they need to save this child's life."
"Cardiogenic shock is still treated with fluid, but we just give less of it, and that's because patients with cardiogenic shock are at very high risk of developing fluid overload."
"Kids are incredibly resilient and they are able to compensate for shock by increasing their heart rate. And they can maintain that for quite a while before their bodies eventually kind of give in and hypotension develops."
Key takeaways on prehospital management of non-traumatic pediatric shock
Marino stressed that early, correct identification of septic or cardiogenic shock in a pediatric patient, and appropriate treatment of each type is vital and achievable using what is already available in the EMS toolbox. She explained what to look for, how to begin treatment, and how to monitor and adjust treatment for each pedatric shock scenario.
1. Septic shock vs. cardiogenic shock – what's the difference?
Shock is the imbalance between oxygen supply and oxygen demand, which decreases organ perfusion and delivery of oxygen to tissues. Left untreated, shock will ultimately lead to organ failure. The different types of shock – such as septic, cardiogenic, anaphylactic, neurogenic and traumatic – all involve the same oxygen supply problem but through different origins, requiring different treatment strategies.
Septic shock is shock that occurs when an infection leads to vasodilation, lowering blood pressure and decreasing organ perfusion. Cardiogenic shock, on the other hand, occurs when the heart is unable to pump well enough to perfuse oxygenated blood throughout the body. These two types of shock may present similarly and be difficult to differentiate, Marino said, which is why it is important to know the different characteristics to look out for.
Patients with septic shock are more likely to present with a fever than those with cardiogenic shock, while those with cardiogenic shock are more likely to show pulmonary and peripheral edema, lung crackles and signs of an enlarged liver than those with sepsis.
Important to note is that patients with underlying medical problems, such as cancer or immune system conditions, are more likely to experience septic shock. Marino said that children with underlying conditions who present with tachycardia and a fever should be presumed to have septic shock, and should receive early and aggressive treatment.
2. Pediatric vs. adult shock
Marino explains that a pediatric patient's heart rate will increase to compensate for shock, and that unlike adults, children are less likely to show hypotension early on. The only symptom present in the early stage of pediatric shock may be tachycardia, and the child may seem fine until the condition has progressed to a later stage.
Marino again stressed the importance of early recognition, as by the time a child shows hypotension, they will have progressed to a late stage of shock and require aggressive fluid resuscitation.
Symptoms seen in the middle stage of shock may show some signs of poor perfusion, such as decreased capillary refill, mottling, decreased peripheral pulses and decreased urine output. Early signs of shock may include fever or hypothermia, but this is not always present.
3. Identify pediatric shock, start fluids and reassess
Early fluid administration is crucial for both septic shock and cardiogenic shock patients, but because cardiogenic shock patients are more susceptible to fluid overload, providers should apply their knowledge of the differences between both types to determine how much fluid to start with.
For patients with septic shock, treatment should begin with a normal saline bolus of 20 mL/kg (max 1,000 mL), while patients with cardiogenic shock should be started on half as much fluid – 10 mL/kg (max 500 mL).
Whether the patient is suspected to have septic or cardiogenic shock, they should always be monitored closely for signs of fluid overload. Providers should observe the patient's response and reassess after each 20 or 10 mL/kg round is administered – if symptoms have not improved, more fluid should be given. If the patient is not responsive to three boluses, the provider should start a dopamine or epinephrine drip for the septic shock patient, and an epinephrine drip of 0.01-0.1 mcg/kg/min for the cardiogenic shock patient.
Marino gave two case examples:
- Case #1. A 10-year-old girl with leukemia presents with a sore throat, fever, tachycardia, signs of poor perfusion and clear breathing sounds. Because the patient is showing tachycardia, has a fever and has an underlying condition, she should be treated for septic shock. The provider should start a normal saline bolus of 20 mL/kg through an IV, or an IO if an IV cannot be started quickly. When the patient's condition has not improved, and no signs of fluid overload are observed, a second bolus should be administered. After the second and third bolus are administered with the same reassessment process and no response, an epinephrine or dopamine drip should be started, and the receiving hospital should be notified.
- Case #2. A 4-year-old previously healthy boy presents with chest pain, fever, tachycardia, signs of poor perfusion and bilateral lung crackles. It is difficult to determine whether the child is experiencing septic or cardiogenic shock, because he has both a fever and lung crackles. However, because he does not have a known underlying condition and there is concern about pulmonary edema, the patient should be started on 10 mL/kg of normal saline and continually assessed.
4. Early treatment of pediatric shock saves lives
The first hour of fluid resuscitation is extremely important when it comes to pediatric shock, especially septic shock. Studies have shown that all patients with septic shock who received >40 mL/kg of saline within the first hour survived, and each hour of persistent shock doubles mortality risk. Marino said that fluid should be administered as quickly as possible once shock is identified, ideally within the first 15 minutes. However, she said that transport should not be delayed for fluid administration, as outcomes for sepsis patients are also improved by early administration of antibiotics.
Additional resources for EMS assessment and treatment of pediatric shock
Learn more about assessing and treating pediatric patients with these resources:
- Sepsis alert: How to diagnose septic shock
- What EMS needs to know about new pediatric sepsis guidelines
- Pediatric sepsis: 10 things paramedics need to know
- Pediatric trauma assessment and treatment tips
- Specialty team activation: 10 things you need to know to save lives
- 3 scenarios to train for diagnosis, treatment of sepsis
- 4 things paramedics need to know about capnography and heart failure