5. PEDIATRIC EMERGENCIES

5.8 PEDIATRIC SHOCK

The most common cause of shock in children is acute volume loss. This can be due to: increased fluid loss (vomiting, diarrhea, hyperthermia, hemorrhage); decreased intake; or fluid shifts out of the vascular space. Regardless of etiology, treatment should be directed at rapid fluid replacement. Severe shock is present if the child exhibits a decreased level of consciousness, weak and thready pulses, no palpable BLOOD PRESSURE, or a capillary refill of more than 2 seconds .

Children are capable of developing significant sinus tachycardia in the face of dehydration, but if the heart rate is greater than 220/minute refer to the Pediatric Supraventricular Tachydysrhythmia Protocol.

ASSESSMENT / TREATMENT PRIORITIES

1. Maintain universal blood and body fluid precautions.

2. In case of suspected head/neck injury, assure cervical spine immobilization / stabilization.

3. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.

4. Administer high concentration of oxygen via non-rebreather mask or assist ventilations as needed.

5. Control external bleeding sources and keep child warm.

6. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs. Evaluate capillary refill and determine if BLOOD PRESSURE is appropriate for age.

7. If in severe shock, position child 15% Trendelenburg or head down.

8. Obtain appropriate history related to event, such as recent illness, change in eating pattern, excessive exercise or heat exposure, trauma, Past Medical History, Medications, Allergies.

TREATMENT

BASIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. In case of suspected head/neck injury, assure cervical spine immobilization / stabilization.

3. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.

4. Administer high concentration of oxygen via non-rebreather mask or assist ventilations as needed.

5. Control external bleeding sources and keep child warm.

6. Activate ALS intercept, if deemed necessary and if available.

7. If in severe shock, position child 15 degrees Trendelenburg or head down.

8. Initiate transport as soon as possible with or without ALS.

9. EMTs with EMT-MAST credentials may contact MEDICAL CONTROL for specific utilization of PASG/MAST for any of the following conditions:

a. suspected pelvic fractures.

b. splinting of lower extremities.

c. to tamponade bleeding from lower extremities.

10. Notify receiving hospital.

INTERMEDIATE PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. In case of suspected head/neck injury, assure cervical spine immobilization / stabilization.

3. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.

4. Administer high concentration of oxygen via non-rebreather mask or assist ventilations as needed.

5. Control external bleeding sources and keep child warm.

6. Activate Paramedic intercept if deemed necessary and if available.

7. If in severe shock, position child 15 degrees Trendelenburg or head down.

8. ALS STANDING ORDERS

a. Provide advanced airway management (endotracheal intubation ONLY), if indicated.

b. Initiate IV Normal Saline (KVO), while en-route to hospital if vein is visible and/or palpable.

9. Initiate transport as soon as possible with or without Paramedics.

10. Contact MEDICAL CONTROL The following may be ordered:

a. Normal Saline bolus at discretion of Medical Control (expected fluid bolus is 20 ml/kg)

b. Specific utilization of PASG/MAST for any of the following conditions:

11. Notify receiving hospital.

PARAMEDIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. In case of suspected head/neck injury, assure cervical spine immobilization / stabilization.

3. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated

4. Administer high concentration of oxygen via non-rebreather mask or assist ventilations as needed.

5. Control external bleeding sources and keep child warm.

6. If in severe shock, position child 15 degrees Trendelenburg or head down.

7. ALS STANDING ORDERS

a. Provide advanced airway management, if indicated.

b. Initiate IV Normal Saline. NOTE: If a vein can be visualized or palpated, establish an IV of Normal Saline KVO. If unable to visualize or palpate a vein and child is less than six years old, establish an intraosseous infusion of Normal Saline to keep the line open. If unable to visualize or palpate a vein and the child is greater than six years old, attempt external jugular access.

c. If severe shock is present, or suspect hypovolemic etiology, administer 20 ml/kg IV Bolus of Normal Saline (unless known history of heart disease)

d. Cardiac Monitoring / dysrhythmia recognition. Treat per protocol if indicated.

e. Specific utilization of PASG/MAST for any of the following conditions:

8. Initiate transport as soon as possible.

9. Contact MEDICAL CONTROL and notify receiving hospital. The following may be ordered:

a. Additional Normal Saline boluses at 20 ml/kg.

b. Intraosseous Infusion of Normal Saline if less than 6 years of age. Once established administer a single bolus of 20 ml/kg of Normal Saline (may be repeated).

c. If known Cardiogenic Shock: Dobutamine (25 mg/ml solution) DOSE: 2-20 mg/kg/minute.

d. If known Cardiogenic Shock: Dopamine (40 mg/ml solution) DOSE: 2-20 mg/kg/minute.

NOTE: Vasopressor medications are never used in the treatment of hypovolemic shock unless adequate fluid replacement has been completed.

10. Notify receiving hospital.






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