Shock: A Common Pathway For Life-Threatening Pediatric Illnesses And Injuries

Silverman, Adam M MD
Wang, Vincent J MD
Kim, Tommy Y MD, FAAP
Whiteman, Paula J MD

¹Authors
²Clinical Fellow, Division of Emergency Medicine, Division of Critical Care Medicine, Childrens Hospital Los Angeles―Los Angeles, CA.
³Attending Physician, Division of Emergency Medicine, Childrens Hospital Los Angeles; Assistant Professor of Clinical Pediatrics, Keck School of Medicine of the University of Southern California―Los Angeles, CA.
⁴Peer Reviewers
⁵Attending Physician, Pediatric Emergency Department; Assistant Professor of Emergency Medicine and Pediatrics, Loma Linda Medical Center and Children's Hospital―Loma Linda, CA.
⁶Medical Director, Pediatric Emergency Medicine, Encino-Tarzana Regional Medical Center; Attending Physician, Cedars-Sinai Medical Center ―Los Angeles, CA.

Date of original release: October 31, 2005.

Date of most recent review: October 28, 2005.

See “Physician CME Information” on back page.

Pediatric Emergency Medicine Practice 2(10):p 1-21, October 2005.

A nurse rushes back from triage with a 7-month-old boy who is minimally responsive, limp, mottled, and pale. The child's breathing is not labored, and his airway seems patent. The nurse quickly hooks up monitors and then starts working to obtain intravenous access. The child has a pulse, and the monitor shows a heart rate of 190 beats per minute, which matches what you feel on examination. The blood pressure cuff inflates, deflates, and recycles without giving a reading. The pulse oximeter shows a poor waveform and also seems unable to yield a reading. After several minutes of failed attempts, the nurse looks up and says, “I don't think I'm going to be able to get this IV in.”

You reach for an intraosseous needle and ― after a quick splash with Betadine® ― punch the needle into the infant's anterior tibia. You ask the nurse to check the glucose on the aspirate from the intraosseous needle and start pushing normal saline into it. Realizing just how sick this kid is now, you ask the clerk to go ahead and call the tertiary children's hospital to arrange transfer. You obtain a little history from the mother. She tells you that her baby is usually healthy, but he has had a couple of episodes of vomiting overnight. He hasn't had any fever or diarrhea. While standing over this child, a number of thoughts come to mind at once: “This kid is obviously in shock.” “Vomiting can be seen with hypovolemic shock, but this history doesn't suggest substantial volume loss.” “Why is this kid in shock?” “If not hypovolemic shock, what kind of shock is this?” “Should I go ahead and intubate this baby?” “When is that transport team from the children's hospital going to call me back?