Pediatric SHOCK Index

SHOCK Basics

Fortunately, the critically ill child is not as common in the Emergency Department as the critically ill adult. Unfortunately, when the critically ill child does arrive, it can be challenging to recognize him/her initially. This can lead to delays in resuscitation care. Even at the extreme point of being pulseless, children can be tricky (See Palpation of Pulse). Then there is always the challenge that having to account for the effect that age has on normal vital signs (See Blood Pressures).  Often, though, by focusing on the Basics, we can met the challenge of detecting Pediatric Shock and act aggressively to treat it!

 

Pediatric Shock

  • Broadly speaking, shock is the state in which there is a failure to meet the metabolic demands of the body leading to anaerobic metabolism. (Mtaweh, 2013)
  • Often categorized as:
    1. Hypovolemic
    2. Cardiogenic
    3. Distributive
      • Toxin mediated – Septic
      • Hypersensitivity reaction – Anaphylaxis
      • Loss of sympathetic tone – Neurogenic

 

Pediatric Shock: A Challenge

  • The diagnosis is initially suspected based upon clinical exam.
  • There is no lab value or “test” that defines shock. (See Lactate)
  • Clinical Findings:
    • Tachycardia
      • Must account for age-adjusted values!
      • Often children present with elevated heart rates without overt illness.
    • Poor Capillary Refill
      • Normal capillary refill can vary with age and is influenced by the environment. (Schriger, 1988)
      • The initial cap refill in the ED, may artificially affected by the pre-hospital environment.
    • Peripheral Pulse Quality
    • Altered Mental Status
    • Cold/Mottled Extremities
    • Poor Urine Output
      • Not likely useful in the initial assessment in the ED.
      • If the patient is “hanging out” in your ED for some time, monitor this!
  • Of these clinical findings, only Altered Mental Status and Poor Peripheral Pulse Quality was associated with development of Organ Dysfunction. (Scott, 2014)
  • No single finding defines shock, but the absence of all of them is reassuring.

 

Pediatric Shock: The Shock Index

  • The Shock Index (Heart Rate / Systolic BP) has been shown to be useful in detecting adult patients with shock.
  • There is evidence that the Shock Index can be useful in pediatric patients also. (Yasaka, 2013; Rousseaux, 2013)
  • Since, pediatric vital signs alter with age, it would make sense to have a “adjusted” tool. (Acker, 2015)
    • Using standard heart rate and systolic BP values for age ranges, Maximum Normal Shock Index values were calculated.
    • Shock Index, Pediatric Adjusted (SIPA)
      • 4-6 years = 1.2
      • 6-12 years = 1
      • > 12 years = 0.9
    • Comparing the patient’s actual HR / Systolic BP to the SIPA was shown to perform better and identify those most severely injured following blunt trauma. (Acker, 2015)
  • Obviously, this may not apply to all pediatric patients presenting with shock, but I do like the concept of utilizing Basic information that is age adjusted.
  • Consider utilizing this tool as another method to help find those subtle presentations of shockRemain Vigilant!

 

References

Acker SN1, Ross JT2, Partrick DA3, Tong S4, Bensard DD5. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg. 2015 Feb;50(2):331-4. PMID: 25638631. [PubMed] [Read by QxMD]

Scott HF1, Donoghue AJ, Gaieski DF, Marchese RF, Mistry RD. Effectiveness of physical exam signs for early detection of critical illness in pediatric systemic inflammatory response syndrome. BMC Emerg Med. 2014 Nov 19;14:24. PMID: 25407007. [PubMed] [Read by QxMD]

Dellinger RP1, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013 Feb;39(2):165-228. PMID: 23361625. [PubMed] [Read by QxMD]

Mtaweh H1, Trakas EV, Su E, Carcillo JA, Aneja RK. Advances in monitoring and management of shock. Pediatr Clin North Am. 2013 Jun;60(3):641-54. PMID: 23639660. [PubMed] [Read by QxMD]

Yasaka Y1, Khemani RG, Markovitz BP. Is shock index associated with outcome in children with sepsis/septic shock?*. Pediatr Crit Care Med. 2013 Oct;14(8):e372-9. PMID: 23962830. [PubMed] [Read by QxMD]

Rousseaux J1, Grandbastien B, Dorkenoo A, Lampin ME, Leteurtre S, Leclerc F. Prognostic value of shock index in children with septic shock. Pediatr Emerg Care. 2013 Oct;29(10):1055-9. PMID: 24076606. [PubMed] [Read by QxMD]

Schriger DL1, Baraff L. Defining normal capillary refill: variation with age, sex, and temperature. Ann Emerg Med. 1988 Sep;17(9):932-5. PMID: 3415066. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. September 16, 2016

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  2. April 28, 2017

    […] us.  We have discussed several topics related to shock previously (ex, Epi vs Dopa, Pediatric Shock Index, and Damage Control Resuscitation), but now let us focus on recognizing SHOCK and one important […]

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