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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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Round one
8. Shock
Statement 8a (Shock recognition and initial management)
Shock can be defined as a physiological state characterised by a significant reduction in systemic tissue perfusion, resulting in decreased tissue oxygen delivery.
|
%
Agree |
%
Disagree |
Result |
|
100% |
0% |
Included |
|
Position |
Comments |
|
ED |
wordy definition “Inadequate tissue perfusion” is enough. ie the focus in this definition is O2 but increased CO2 may be just as damaging |
Statement 8b
(i) Shock can be recognised clinically if one or more of the following signs are present in a child with reduced conscious level:
|
Cold shock (hypovolaemic and cardiogenic shock) |
|
Capillary refill time > 2 seconds |
|
Mottled cool extremities |
|
Diminished peripheral pulses |
|
Systolic blood pressure is less than 5th percentile for age |
|
Decreased urine output <1ml/kg/hour |
|
%
Agree |
%
Disagree |
Result |
|
87.5% |
9.4% |
Included |
|
Position |
Comments |
|
ED |
Each of these signs consistent with a diagnosis of shock, though most not diagnostic in isolation |
|
PICU |
There are consensus statements on the definition of shock in children (see Carcillo et al) |
|
Metab |
A rather subjective response, I confess |
|
Neuro |
I don’t really know how to answer this. I don’t think any of these alone is sufficient. When defined clinically, shock is a syndrome. As such, I think there always needs to be a constellation of features. All of the above are certainly features of shock, but for each of them there are alternative (often physiological) cause |
|
ED P |
CRT should take account of ambient temperature |
|
Renal |
Anuria in isolation could be due to acute renal failure |
|
ED P |
But could have CRT>2 sec + decreased urine output if not drinking/vomiting and just come from cold unless measured centrally |
|
Metab |
One sign insufficient – as child may simply be v cold – 2 or more therefore. Urine signs only applies with time. |
|
PICU N |
Need to take account of history, is he a snowboarder? |
|
Endo |
I disagree if one is only mottled, cool extremities |
|
Paed |
one alone is not sufficient because other causes of sign in isolation (cold room etc) |
|
Paed |
after allowance for cold environment in A+E |
(ii) Shock can be recognised clinically if one or more of the following signs are present in a child with reduced conscious level:
|
Warm shock (distributive shock) |
|
“Flash” capillary refill time |
|
Bounding peripheral pulses |
|
Systolic blood pressure is less than 5th percentile for age |
|
Decreased urine output <1ml/kg/hour |
|
%
Agree |
%
Disagree |
Result |
|
82.8% |
10.3% |
Included |
|
Position |
Comments |
|
ED |
Each of these signs consistent with a diagnosis of shock, though most not diagnostic in isolation. |
|
Metab |
A rather subjective response, I confess |
|
PICU |
difficult as an isolated entity/more appropriate if more than one present- |
|
Renal |
Anuria in isolation could be due to acute renal failure |
|
Neuro |
I don’t really know how to answer this. I don’t think any of these alone is sufficient. When defined clinically, shock is a syndrome. As such, I think there always needs to be a constellation of features. All of the above are certainly features of shock, but for each of them there are alternative (often physiological) cause |
|
Paed |
one alone is not sufficient because other causes of sign in isolation (cold room etc) |
|
Endo |
“flash” – not sure what this means. Bounding pulses could be high CO2 |
|
Metab |
Often only a brief phase! Don’t find the cold/warm distinction helpful. Unfamiliar with “Flash” term – not in APLS manual. |
|
PICU |
cap refill may not flash. mixed venous gas may help |
|
Paed |
metabolic acidosis on blood gas helpful in this situation |
(iii) Shock can be defined as being present in a child with reduced conscious level if the capillary refill time is greater than 2 seconds, the heart rate is above the normal range for age and the blood pressure is below the normal range for age.
|
%
Agree |
%
Disagree |
Result |
|
81.3% |
3.1% |
Included |
|
Position |
Comments |
|
Paed |
This would only be decompensated shock and would exclude all those with compensated shock |
|
Metab |
A rather subjective response, I confess |
|
Paed |
may not need BP low as well |
|
Neuro |
But BP often maintained until advanced stage |
|
Endo |
Decreased BP may be late |
|
PICU |
there is a danger all above secondary purely to CNS primary process not shock |
|
Paed |
BP unnecessary |
Statement 8c
If shock is present in a child with a reduced conscious level, look for signs of:
(i) sepsis (definition of sepsis addressed later)
|
%
Agree |
%
Disagree |
Result |
|
100% |
0% |
Included |
(ii) trauma (blood loss, tension pneumothorax, cardiac tamponade)
|
%
Agree |
%
Disagree |
Result |
|
100% |
0% |
Included |
|
Position |
Comment |
|
Neuro |
Less likely, except in NAI |
(iii) anaphylaxis (urticarial rash, wheeze, stridor, swollen lips/tongue)
|
%
Agree |
%
Disagree |
Result |
|
100% |
0% |
Included |
(iv) heart failure (enlarged liver, peripheral oedema, distended neck veins, heart murmur)
|
%
Agree |
%
Disagree |
Result |
|
94.1% |
0% |
Included |
|
Position |
Comments |
|
PICU |
Especially in congenital heart disease. Distended veins and peripheral oedema unreliable in kids |
|
Paed |
(respiratory compromise) |
(v) Shock in a child with a reduced conscious level is not a
diagnosis in itself and so the core investigations should be requested to
determine the cause (“core investigations” will be defined as the investigations agreed
upon in Statement 7d)
|
%
Agree |
%
Disagree |
Result |
|
91.2% |
0% |
Included |
|
Position |
Comments |
|
ED |
Agree, although not all the core investigations may be required if the cause of shock is otherwise clinically apparent |
|
ED |
In trauma, bleedin from an open # doesn’t need any Ix to determine the immediate cause and treat it. I think shock is a diagnosis with multiple aetiologies! (and these need to be excluded or confirmed) |
|
Paed |
may be the cause but core Ix should be Ix for |
Statement 8d
(i) If shock is present in a child with a reduced conscious level, a bolus of 20 ml per kg of either crystalloid or colloid should be given.
|
%
Agree |
%
Disagree |
Result |
|
86.2% |
3.4% |
Included |
|
Position |
Comments |
|
Paed |
Crystalloid for first one |
|
Paed |
No reason to start with colloid unless obvious major blood loss |
|
Paed |
Not if it is cardiogenic shock |
|
Renal |
Colloid should be kept in reserve for specific situations (septic shock, nephritic syndrome, burns) |
|
PICU |
as initial Rx |
(ii) If shock is present in a child with a reduced conscious level, a bolus of 20 ml per kg of crystalloid should be given, unless the cause of shock is most likely sepsis in which case 20 ml per kg of colloid should be administered.
|
%
Agree |
%
Disagree |
Result |
|
53.8% |
23.1% |
Excluded |
Statement 8e
(i) The response to a fluid bolus should be monitored by heart rate, capillary refill time, urine output and level of consciousness.
|
%
Agree |
%
Disagree |
Result |
|
96.7% |
0% |
Included |
|
Position |
Comments |
|
ED |
Though not necessarily all at the same time eg urine output may be later |
|
PICU N |
and BP |
|
PICU |
cap gas/art gas obtained, BP measured. bloods obtained esp U+E, LFTs inter alia |
(ii) A positive response to a fluid bolus can be defined as a reduction in tachycardia, a reduction in a prolonged capillary refill time, an increase in urine output and an improvement in the level of consciousness.
|
%
Agree |
%
Disagree |
Result |
|
96.7% |
0% |
Included |
|
Position |
Comments |
|
Metab |
Too many options, possibly too insensitive |
|
PICU N |
and BP |
|
Metab |
“increase in urine output” – assume catheter in place, otherwise hard to record with time etc. Rest more tangible signs |
|
PICU |
partial definition – above true… Takes some time to be sure of above |
Statement 8f
(i) Further fluid therapy should be guided by clinical response.
|
%
Agree |
%
Disagree |
Result |
|
90.9% |
0% |
Included |
|
Position |
Comments |
|
Metab |
Too vague |
|
Neuro |
I am unsure what you mean by clinical response. Invasive monitoring (CVP etc) may be appropriate, is this included? |
|
PICU |
and further assessment |
|
Paed |
extreme caution in children and further fluid boluses guided by experienced paediatricians |
(ii) Fluid boluses of up to and over 60 ml pre kg may be required, guided by clinical response.
|
%
Agree |
%
Disagree |
Result |
|
96.8% |
3.2% |
Included |
|
Position |
Comments |
|
Neuro |
Sometimes by CVP |
|
Metab |
I’ve never used such high volumes |
|
Renal |
Only in discussion with intensivists |
|
PICU N |
sometimes three times this amount |
|
PICU |
unlikely unless sepsis |
|
Paed |
care/care |
(iii) If more than 40 ml per kg has been given, the child should be intubated and ventilated to prevent uncontrolled pulmonary oedema developing.
|
%
Agree |
%
Disagree |
Result |
|
60% |
4% |
Discussed
in round 2 |
|
Position |
Comments |
|
ED P |
Intubation and ventilation should be considered |
|
ED |
The need for intubation and ventilation should be determined |
|
ED |
Intubation and ventilation should be seriously considered |
|
Neuro |
it should be considered….but observation may be possible |
|
ED |
depends on clinical cause, but likely to be the case that severe fluid replacement will occur in patients needing intubation for other reasons |
|
PICU |
may often need more fluid without intubation in reality but should always think about it and inform PICU |
|
Endo |
“usually” be intubated |
|
ED P |
Not always necessary at this level |
|
Neuro |
Should be intubated but not to prevent pulmonary oedema developing primarily |
|
PICU N |
or at least thinking about ventilation |
|
Paed |
Consideration for intubation. Anaesthetist informed, HDU observation |
|
PICU |
generally intubation required – allows further Ix and monitoring too which helps manage |
(iv) If more than 40 ml per kg has been given with little clinical response, inotropic support should be initiated.
|
%
Agree |
%
Disagree |
Result |
|
63.3% |
6.7% |
Discussed
in round 2 |
Statement 8g
Children with a reduced conscious level and shock which has been unresponsive to 40 ml per kg should be monitored on an intensive care unit.
|
%
Agree |
%
Disagree |
Result |
|
87.9% |
0% |
Included |
|
Position |
Comments |
|
PICU N |
or equal high dependency |
|
PICU |
stability should be attained before moving anywhere |
|
ED P |
Or HDU |
|
ED P |
HDU if available unless requires intubation |
|
Paed |
depends on HDU facilities. In our hospital needs ITU |
|
Neuro |
HDU definitely but not PICU |
|
Endo |
?high dependency – depends on local facilities |
|
Metab |
I would have assumed that statement correct even without “which has been unresponsive to 40ml per kg” phrase |
|
PICU |
will need 1:1 not necessarily PICU – HDU initially |