Memorizing these vital
signs is not important,
but I bring it up to remind
you that in pediatrics,
we have the unique problem of needing
to know what is a normal heart rate,
a normal respiratory rate
and a normal blood pressure
for infants and children as these
numbers change as we get older.
So younger infants generally have a
higher heart rate and respiratory rate
and a lower blood pressure as a
normal value than older kids.
Remember, airway, breathing, circulation,
this is where you’re going to
get a lot of that information
and having a sense of what are
normal values is important.
So spend some time looking this chart over
as you’re familiarizing yourself
with vital signs in children.
So what are the things we need to do?
A patient comes in with shock,
generally the first thing we need
to do is support that circulation.
So obviously, if there’s
an obstructive shock,
before we’re giving IV fluids, we need to
do an emergent fix of the obstruction.
So for example, in a tension pneumothorax,
before giving IV fluids, we really
need to do a needle compression
and you can check how to do that in
our tension pneumothorax lecture.
After those immediate interventions,
we typically would give boluses.
And the amount of bolus
is 20 cc’s per kilo.
You should memorize that number.
And we usually give that over 20 minutes,
but you can certainly give it faster
in a patient with acute
We may repeat these boluses
up to usually once, sometimes
twice, rarely three times.
By the time you’re giving a fourth
bolus, you’re probably making a mistake.
These patients now probably
aren’t that dehydrated
or hypovolemic unless
there’s ongoing losses
and you might consider another approach
towards maintaining a higher pressure.
The reason being is you can actually fluid
overload with someone who is in shock.
And if you fluid overload them, the
lungs become filled with fluid
and they can be harder to
engage in the resuscitation
in terms of the acid-base
status with the breathing.
So you don’t want to
make things worse.
So after three boluses, you
should start to think about
alternative methods for maintaining
blood pressure support.
So what are those?
Well, generally, in children,
we start with dopamine.
So, dopamine has both
beta 1 and beta 2 effects
and it is a first line pressor
supportive drug for children.
It increases also cardiac
output, which can’t hurt.
And it increases the systemic
Other options include for anaphylactic
shock, we’ll give epinephrine.
We sometimes give norepinephrine
for a warm distributive shock,
though norepinephrine is rarely a
first-line agent for blood pressure support
and for cardiogenic shock,
we may give dobutamine.
Sometimes we’re not sure what’s going in
before the dopamine is already on board
and then we can switch agents.
So that’s my review of the
management of shock in children.
Thanks for your attention.