Shock: recognition and resuscitation

Manage now— do this, in order

• Treat and diagnose at the same time: oxygen titrated to SpO₂ 92–95%; two peripheral cannulae of 16 or 18 gauge (intraosseous if peripheral access fails in a peri-arrest patient); catheterise for hourly urine, attach monitoring, record a 12-lead ECG and capillary glucose.Doctor / Nurse
• Fluid by type of shock: septic/distributive — 30 mL/kg in the first hour as 500 mL aliquots with reassessment after each (children 10–20 mL/kg over 10–20 minutes); haemorrhagic — blood, not crystalloid (crystalloid is a bridge only); cardiogenic — 250 mL challenges only, auscultating the chest after each; massive PE — 500 mL of 0.9% sodium chloride then stop. Prefer balanced crystalloid; never hydroxyethyl starch.Doctor / Nurse
• Reassess the same five things after every bolus: pulse and blood pressure; capillary refill and peripheral temperature; respiratory rate and oxygen requirement; the lung bases for new crackles; and mental state. Stop and reconsider on new basal crackles, rising oxygen requirement, visibly raised JVP, or no improvement after 30 mL/kg — in children, if shock persists after 40 mL/kg consider elective intubation rather than further boluses.
• Noradrenaline is the first-line vasopressor: start 4–8 microgram/min IV (about 0.05–0.1 microgram/kg/min), titrate every 5 minutes to MAP of at least 65 mmHg; refractory shock may need 10–30 microgram/min; children 0.05–0.1 microgram/kg/min. In severe hypotension do not wait until 30 mL/kg has been given.Doctor / NurseNot available at your setup — Infusion pump.
• Anaphylaxis: remove the trigger and give adrenaline 500 microgram (0.5 mL of 1:1000) IM into the anterolateral thigh, repeated every 5 minutes if no improvement — children 10 microgram/kg IM (150 microgram under 6 years, 300 at 6–12, 500 over 12) — with generous IV crystalloid; antihistamine and corticosteroid are adjuncts, never substitutes.
• Antibiotics within one hour of recognising septic shock, after cultures where these can be taken promptly — inability to obtain cultures must not delay treatment. Paediatric first-hour cover: ceftriaxone 80 mg/kg IV once daily or cefotaxime 50 mg/kg IV 6-hourly (neonates under 28 days: cefotaxime plus amoxicillin or ampicillin). In severe invasive group A streptococcal infection add clindamycin 900 mg IV 8-hourly to benzylpenicillin 2.4 g IV 4-hourly. Drain the source.Doctor / NurseNot available at your setup — Blood culture.
• Suspected adrenal crisis: hydrocortisone 100 mg IV immediately with fluid and glucose (children 2 mg/kg IV, maximum 100 mg) — do not wait for a cortisol result; in septic shock with an ongoing vasopressor requirement give hydrocortisone 50 mg IV 6-hourly.Doctor / Nurse
• Mechanical emergencies: tension pneumothorax — immediate needle decompression before any imaging, then an intercostal drain; tamponade — fluid to maintain filling, then pericardiocentesis or surgical drainage; bradycardia with hypotension — atropine 500 microgram IV every 3–5 minutes to a maximum of 3 mg (children 20 microgram/kg, minimum 100, maximum 600 microgram).Doctor / NurseNot available at your setup — Chest drain / tube thoracostomy.
• Never give nitrates or diuretics in right ventricular infarction — give fluid instead, and avoid nitrates when the systolic pressure is below 90 mmHg.