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Shock · 1
Circulatory Emergencies:
Shock (Hypoperfusion)
Note: Throughout this chapter, the term “shock” will be used to refer to shock
(hypoperfusion) syndrome as defined in the National Standard Curriculum.
 WHAT YOU’LL COVER
 Key differences between early and late shock in children
 Assessment findings that indicate pediatric shock
 Appropriate interventions for early and late shock
 Mechanisms that can cause shock
 CHAPTER CONTENTS
Glossary
Learning Objectives and Key Points
NSC Objectives
Assessment and Management
Causes of shock in children
First impression
Initial assessment
CUPS assessment
Focused history
Detailed physical examination
Enrichment
Barriers to Learning
Practice Sessions
References
Tables
First Impression of Pediatric Shock
Circulatory Assessment Findings for Pediatric Shock
Pediatric Pulse Rates
Low-Normal Pediatric Systolic Blood Pressure
CUPS Assessment for Pediatric Shock
Handouts
Key Points: Pediatric Shock (Hypoperfusion)
CUPS Assessment for Pediatric Shock
Assessment Findings for Pediatric Shock
Managing a Serious Allergic Reaction
Pediatric Pulse Rates
Low-Normal Pediatric Systolic Blood Pressure
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Shock · 2
 GLOSSARY
The following specialized terms are used in this chapter:
abdomen–portion of the trunk between the chest
and pelvis; the stomach region
abdominal–relating to the abdomen
anaphylactic–relating to an allergic reaction
anaphylactic shock–type of shock caused by a
severe allergic reaction
brachial pulse–pulse found at the inner side of the
upper arm
cardiogenic–arising from the heart
cardiogenic shock–type of shock caused when the
heart is unable to pump blood effectively
cardiopulmonary–relating to the heart and lungs
carotid pulse–pulse found at either side of the
neck
dehydration–loss of water or fluid from the body
distributive shock–type of shock resulting when
blood vessels enlarge, causing blood pressure
to fall
ecchymosis–skin discoloration caused by bleeding
into the skin or underlying tissue; a bruise
epinephrine–medication used to treat severe
allergic reactions
femoral pulse–pulse found in the groin area at the
top of the thigh
hemorrhagic shock–type of shock caused by
internal or external bleeding
HIV–human immunodeficiency virus, the virus
that causes acquired immune deficiency
syndrome (AIDS)
hypoperfusion–another name for shock
hypovolemic–relating to low blood volume
hypovolemic shock–type of shock caused by low
blood volume, which arises from loss of blood
or other body fluids
laceration–a cut
neurogenic–arising from the nerves
neurogenic shock–type of shock caused by spinal
cord damage
perfusion–the flow of blood through the blood
vessels and skin
peripheral–outer part or surface
septic–relating to the presence of infection-causing
organisms in the blood or tissues
septic shock–type of shock caused by serious
infection
shock–the body’s reaction when blood circulation
fails; also called hypoperfusion
sign–assessment finding that indicates illness or
injury
stridor–a high- or low-pitched breath sound
produced during inhalation when the upper
airway passages are partially blocked
symptom–an indication of illness described by the
patient or parent
syndrome–a group of signs and symptoms that
together indicate a disease or abnormal
condition
systolic blood pressure–the higher of two blood
pressure measurements, which occurs when
the heart is actively pumping
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 LEARNING OBJECTIVES AND KEY POINTS
After teaching your students about pediatric shock, they should be able to perform the learning
objectives below. Each objective relates to a key point drawn from chapter content. Key points
are repeated in a student handout at the end of the chapter.
Learning Objectives
Key Points
name the two most
common causes of shock in
children
 The two main causes of shock in children are (1) bleeding from
traumatic injuries, and (2) body fluid loss from vomiting and
diarrhea.
list four less common
causes of shock in children
 Less common causes of shock in children include blood infections,
severe allergic reactions, serious burns, spinal cord damage, heart
problems, and diabetes.
list four assessment
findings that are typical of
children in early shock
 Children in early shock often appear well, with a strong central
pulse and a good first impression. Initial assessment findings for
early shock include a fast pulse rate and abnormal skin findings
(bluish color, cool temperature, and slow capillary refill time),
weak peripheral pulses, and sometimes a slight change in mental
status.
list five assessment
findings that are typical of
children in late shock
 When children progress to late shock, their condition worsens
suddenly and rapidly. Assessment findings for late shock include a
poor first impression, decreased responsiveness, poor muscle tone,
airway and breathing problems, and a weak central pulse. (In
children, a weak central pulse is associated with low blood
pressure.) Peripheral pulses are absent. The central pulse rate may
be very fast or slow, and capillary refill time is greatly delayed
(longer than five seconds).
describe the method to
measure blood pressure in
children aged three years
or younger
 Blood pressure need not be measured in children aged three years
or younger, as a strong central pulse is evidence of adequate blood
pressure at this age. Use a blood pressure cuff only on children
older than three years.
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Shock · 4
list two focused history findings
that suggest a potential for
early shock in children
 EMTs should assess carefully  To treat a child who shows signs of early shock, EMTs should
for early shock if the child’s
give high-concentration oxygen, control external bleeding, place
history includes any of the
the child in shock position (legs slightly elevated), and keep the
following: significant loss of
child warm. Consider ALS backup and transport to a pediatric
blood or other body fluids;
critical care center.
serious infection; allergic
reactions to foods, medications,
or insect stings; severe burns;
spinal cord injury; heart
problems; or diabetes.describe
four steps to take in treating
early pediatric shock
describe six steps that may be
necessary in treating late
pediatric shock
 To treat a child who shows signs of late shock, EMTs may need
to open and maintain the airway. Give high-concentration
oxygen (using assisted ventilation if needed), control external
bleeding, place the child in shock position, and keep the child
warm. Children in late shock are likely to require ALS backup
and transport to a pediatric critical care center.
 NSC OBJECTIVES
Information in this chapter will support your teaching of the following objectives from the
EMT-Basic: National Standard Curriculum:
1–5.5 Describe methods to obtain pulse rate
1–5.6 Identify information obtained when assessing a pulse
1–5.7 Differentiate between strong, weak, regular, and irregular pulse
1–5.8 Describe methods to assess skin color, temperature, and condition (capillary refill)
1–5.14 Identify normal and abnormal capillary refill in infants and children
1–5.16 Identify normal and abnormal pupil size
4–7.8 Discuss the emergency medical care of bites and stings
5–1.9 List the signs and symptoms of shock (hypoperfusion)
5–1.10 List the steps in the emergency medical care of the patient with signs and symptoms of
shock (hypoperfusion)
5–1.11 Explain the sense of urgency to transport patients who are bleeding and show signs of
shock (hypoperfusion)
6–1.8 Identify the signs and symptoms of shock (hypoperfusion) in the infant and child
patient
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Shock · 5
 ASSESSMENT AND MANAGEMENT
 Key Point
The two main causes of
shock in children are (1)
bleeding from traumatic
injuries, and (2) body fluid
loss from vomiting and
diarrhea.
Causes of Shock in Children
Shock occurs when blood circulation fails. In children, the
two most common causes of shock are

traumatic injury that results in serious internal or external
bleeding, such as a motor vehicle crash, a significant fall,
or a penetrating injury

repeated vomiting or diarrhea, particularly in infants and
young children, especially if the child is also not drinking
A reported history of significant injury or repeated vomiting
and diarrhea should alert EMTs to assess carefully for early
shock.
 Key Point
Less common causes of
shock include blood
infections, severe allergic
reactions, serious burns,
spinal cord damage, heart
problems, and diabetes.
Less common causes of shock include
 serious infections
 allergic reactions to foods, medications, or insect stings
 severe burns
 spinal cord injury
 heart problems
 diabetes
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sessment
Shock · 6
Recognizing early shock in children and treating it before it
worsens into late shock can greatly improve outcome.
However, children who are in early shock may have few signs
that are immediately obvious to EMTs upon arrival. To
confirm early shock, EMTs usually have to evaluate the
circulatory findings from the initial assessment and ask
focused history questions. Knowing that the factors listed
above may lead to shock in children can help EMTs recognize
early shock more quickly during their assessment.
First Impression
To form a first impression of the child’s condition, EMTs
should assess mental status, muscle tone and body position,
visible breathing movement, breathing effort, and skin color.
First impression findings that suggest early and late shock are
summarized in the accompanying table.
First Impression of Pediatric Shock
Normal
Early
Late
al status
Alert,
responsive
Anxious, agitated
Decreased
responsiveness
le tone/
position
Normal, able to
sit
Normal or somewhat
limp
Limp
hing: visible
ment
Present
Present
Present
hing effort
Normal
Slightly increased
Usually increased;
sometimes decreased
color
mities)
Normal
Normal, pale, or
mottled
Very pale, mottled, or
blue
ns
Work at
moderate pace
through
focused history
and detailed
physical exam
Move quickly
to initial assessment,
give highconcentration
oxygen, control
bleeding
Open airway, suction,
give highconcentration
oxygen, assist
ventilation
as needed, control
bleeding
mpression of early shock  A child who is in early shock may appear slightly agitated and pale.
However, these signs could simply mean that the child is anxious. If EMTs learn that one or
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Shock · 7
more risk factors for shock is present in a child with a good first impression, they should
move in for the initial assessment a little more quickly than they would for the nonurgent
child who has no history to suggest shock. They will need to pay close attention to
circulatory assessment findings, which will help them confirm whether early shock is
present.
First impression of late shock  A child in late shock has a poor first impression.
EMTs will see that the child is limp, with decreased responsiveness and mottled or
bluish skin. Usually they will see signs of increased breathing effort, although
sometimes effort decreases in late shock. When EMTs see a child with this appearance,
they should approach quickly to begin initial assessment and interventions for ABCs.
Initial Assessment
EMTs should proceed with assessment and management of the airway, breathing,
circulation, and mental status, basing their approach on their first impression of the child’s
condition.
Airway and breathing  Children in early shock can usually maintain the airway without
assistance unless there are complicating factors such as trauma. The breathing effort may
be slightly increased and the rate may be somewhat fast for the child’s age.
Children in late shock may be unable to maintain their airway without assistance. They
may show signs of respiratory failure, including blueness around the mouth and lips and
rapid, shallow breathing. EMTs should reassess breathing frequently and begin bag-valvemask ventilation if these signs develop.
Airway and breathing interventions for early shock
 Key Point
Children in early shock
often appear well, with a
strong central pulse and a
good first impression. Initial
assessment findings include
a fast pulse rate, bluish, cool
skin, slow capillary refill
time, weak peripheral
pulses, and altered mental
status.

If trauma is suspected, immobilize the cervical spine. Open airway if necessary.

All children with possible early shock should be given high-concentration oxygen. Use
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Shock · 8
a nonrebreather mask if the patient will accept it.

Control external bleeding, if present.
NOTE
EMTs should observe universal precautions
before performing any intervention that may
involve contact with blood, vomit, or secretions.
 Enrichment point
Oxygen and shock: When a child is in shock, maintaining the airway and
 Key Point
providing supplemental high-concentration oxygen is of primary importance.
This is because any problem that affects the heart and circulation will affect the
airway and breathing—and ineffective breathing, in turn, worsens circulatory
problems, contributing to a potentially deadly cycle. Giving high-concentration
oxygen to a child in shock can lessen the effects of low blood oxygen on vital
organs. In some cases, giving oxygen will slow the progression of early shock,
potentially improving outcome.
When children progress to
late shock, their condition
worsens rapidly. Assessment
findings include a poor first
impression, decreased
responsiveness, poor muscle
tone, airway and breathing
problems, a weak central
pulse, absent peripheral
Airway and breathing interventions for late shock
pulses, and very slow
 Open and maintain the airway as needed, immobilizing the cervical spine first capillary refill.
if trauma is suspected.

Administer high-concentration oxygen. Gently suction mouth and nose if
necessary. Repeat oxygen after suctioning.

Provide assisted ventilation using a bag-valve-mask device if the child shows
signs of respiratory failure.

Control external bleeding if present.

If no trauma is suspected, place child in shock position (legs slightly
elevated).

Move rapidly to assessment of circulation and prepare for transport.
Circulation  In children with a good first impression, circulatory assessment
findings can alert EMTs to the presence of early shock. EMTs should continue to
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Shock · 9
control any obvious, rapid bleeding as they perform the circulatory assessment.
They should assess central and peripheral pulses, pulse rate, skin color and
temperature, and capillary refill rate. They may consider measuring blood
pressure in children older than three years. This should be done at the end of the
circulatory assessment. If the child’s condition is urgent, transport should not be
delayed to obtain a blood pressure reading.
The accompanying table summarizes circulatory assessment findings for early
and late shock. EMTs should keep in mind that there is no clear-cut line between
these stages of shock and children may not have all the findings typical of each
stage. Management actions should be based on the more serious findings present.
Circulatory Assessment Findings for Pediatric Shock
Assessment
Normal
Early
Late
Pulse rate
Normal
Fast
Very fast or slow
Central pulse
Normal
Normal
Weak
Periph pulse
Normal
Weak
Absent
Skin color
(extremities)
Normal
Normal, pale, or
mottled
Very pale, mottled,
or blue
Skin temp
Normal
Cool
Cool
Capill refill
2–3 seconds
3–5 seconds
More than 5 seconds
BP*
Normal for age
Normal for age
Low for age
Actions
Work at moderate
pace through
focused history and
detailed physical
exam
Move quickly;
give highconcentration
oxygen, control
external
bleeding, reassess
frequently
Open airway, suction,
give highconcentration
oxygen, assist
ventilation
as needed, control
external bleeding
*In children aged three years or younger, a strong central pulse is a good indication of adequate blood pressure.
To assess circulation, EMTs should perform the following steps:
· Feel for the presence of a central pulse at the brachial, femoral, or carotid site.
If present, note whether the pulse is strong or weak. In children aged three years or
younger, a strong central pulse is a good indication of adequate blood pressure.

Count the central pulse rate for thirty seconds and double this figure to find
the pulse rate. Normal pulse rates are age-dependent and are listed in the
following table.
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Pediatric Pulse Rates
Age
Low
High
Infant (birth–1 year)
100
160
Toddler (1–3 years)
90
150
Preschooler (3–6 years)
80
140
School-age (6–12 years)
70
120
Adolescent (12–18 years)
60
100
Pulse rates for a child who is sleeping may be 10 percent lower
than the low rate listed.
 Enrichment point
Pulse rate in pediatric shock: During early shock,
children respond to loss of blood or fluid volume
with an abnormally fast pulse rate. This helps to
deliver as much blood and oxygen as possible to
the brain, heart, and lungs. As the child tires and
late shock sets in, the supply of oxygen can no
longer support effective pumping of the heart
muscle and the pulse rate slows. Infants and
younger children tolerate a slow pulse rate poorly
and will quickly progress to cardiopulmonary
arrest if left untreated.
 Enrichment point
Estimating pulse rates: If a table of pediatric pulse
rates is not available, EMTs can estimate the upper
limit for a child’s normal pulse rate using the
following equation: Rate=150-(5age in years). In
other words, multiply the child’s age by 5, then
subtract the result from 150. For example, in a
seven-year-old child, the upper limit would be
150-(57), or 115. Although this is not exact, it
provides a good estimate.

Keeping one hand on the central pulse point,
find the peripheral pulse (at the wrist or top of
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Shock · 11
the foot) with the other hand. The peripheral
pulse should feel nearly as strong as the central
pulse.
· Check skin color, temperature, and capillary
refill time. Normal skin color is pink. Normal skin
temperature is warm, and capillary refill time should be
two to three seconds. A longer capillary refill time and
skin that is pale, mottled, or bluish and cool can indicate
shock.
 Enrichment point
Capillary refill in a cold environment: When a
child’s skin is cold, capillary refill time may be
slower. If EMTs measure the refill time in the hand
or fingers and find it slow, they should recheck it
in a more central location, such as the forehead or
chest, before assuming that early shock is present,
particularly if all other circulatory assessment
findings are normal.

In children older than three years, measure
blood pressure after completing the rest of the
circulatory assessment. Unless the patient’s
condition is nonurgent, this measurement
should be made only after transport is
underway. Normal blood pressures are agedependent and are shown in the accompanying
table.
Low-Normal Pediatric Systolic Blood Pressure
Age*
Low Normal
Infant (birth–1 year)
greater than 60*
Toddler (1–3 years)
greater than 70*
Preschooler (3–6 years)
greater than 75
School-age (6–12 years)
greater than 80
Adolescent (12–18 years)
greater than 90
 Key Point
In children aged three years
or younger, a strong central
pulse is evidence of
adequate blood pressure.
Use a blood pressure cuff
only on older children.
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Shock · 12
*Note: In infants and children aged three years or younger,
the presence of a strong central pulse should be substituted
for a blood pressure reading.
 Enrichment point
Estimating blood pressure: If a table of pediatric
blood pressure rates is not available, EMTs can
estimate the lower limit for a child’s normal
systolic blood pressure using the following
equation: BP=(2age in years)70. In other
words, double the child’s age in years and add 70.
For example, a seven-year-old child’s low-normal
blood pressure would be (27)70, or 84.
Although this is not exact, it provides a good
estimate.

Keep in mind that it can be difficult to get an
accurate blood pressure reading in young
children. If the blood pressure reading is low in
a well-appearing child whose other assessment
findings are normal, EMTs should carefully
recheck the circulatory assessment findings and
then try measuring the blood pressure again. If
the second measurement is low, consider the
child potentially unstable.

If EMTs are unable to obtain any blood
pressure reading, they should base treatment on
other assessment findings for perfusion,
including pulse rate, strength of pulses, skin
color and temperature, capillary refill time, and
mental status. (The same holds true if EMTs
are unable to feel a central pulse in a child aged
three years or younger: They would then base
their assessment and interventions on skin
color and temperature, capillary refill time, and
mental status.)
Interventions during circulation assessment
 Control external bleeding with firm pressure.

In children who have appeared stable so far,
 Key Point
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Shock · 13
decide whether circulatory assessment findings
indicate early shock. If so, make sure the child
is receiving high-concentration oxygen.
Elevate the legs slightly only if there is no
possibility of injury to the head, spine, or
pelvis. Keep the child warm. Be prepared to
reassess the need for assisted ventilation.

Children with signs of late shock should be
receiving high-concentration oxygen. Provide
assisted ventilation if necessary. Elevate the
legs slightly only if there is no possibility of
injury to the head, spine, or pelvis. If trauma is
possible, immobilize the child on a spine board
and raise the bottom of the board a few inches.
Keep the child warm. (See Figure 10: Shock
Position.)

Recheck the pulse frequently in any child who
is receiving assisted ventilation. Begin chest
compressions if any of the following applies:
(1) a newborn has a pulse rate slower than
eighty beats per minute and not rising; (2) a
newborn, infant, or child of any age has a pulse
rate slower than sixty beats per minute with
signs of shock or poor peripheral perfusion; or
(3) a newborn, infant, or child of any age has
no pulse. For newborns, deliver three
compressions for each ventilation until the
pulse rate exceeds eighty; for infants and
children, deliver five compressions for each
ventilation until the pulse rate exceeds sixty.

Depending on regional protocols, a pneumatic
anti-shock garment (PASG) may be used to
treat a child who has signs of shock and an
unstable pelvis. Do not apply a PASG if there
are penetrating injuries above waist level.
Watch breathing carefully and deflate the
abdominal compartment if signs of respiratory
distress develop. More information appears in
Traumatic Emergencies.
To treat a child who shows
signs of early shock, give
oxygen, control external
bleeding, place the child in
shock position, and keep the
child warm.
Children who show signs of
late shock may require
airway opening and assisted
ventilation in addition to the
measures listed above.
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Mental status  EMTs should complete the initial
assessment by determining whether the child is
alert, unresponsive, or responds only to verbal or
painful stimulus. Both early and late shock can
alter a child’s mental status. In early shock the
child may appear alert but agitated. Children in late
shock may have decreased responsiveness with a
mental status of V, P, or U.
Interventions during mental status assessment
If the child responds only to voice, EMTs should
provide high-concentration oxygen. If the child
responds only to pain or is unresponsive, EMTs
may need to provide assisted ventilation as well.
Initiate transport before beginning the focused
history or detailed physical exam for any child who
is not alert.
 Enrichment point
What the signs mean: Mental status is a reliable indicator of whether the blood is carrying
enough oxygen to the child’s brain. Children who do not have enough oxygen-carrying
blood reaching the brain often act anxious or agitated, as seen in early shock. Children
who have severely decreased amounts of oxygen-carrying blood in the brain become
sleepy or unresponsive, a sign of late shock.
CUPS Assessment
Following initial assessment and treatment, a triage decision should be made based on
CUPS assessment. A child who shows signs of late shock has a CUPS status of C
(critical). A child who shows signs of early shock has a CUPS status of U (unstable). If a
child appears stable but has a mechanism of injury or illness that could cause shock (such
as significant blood or fluid loss), EMTs should consider the child’s condition P
(potentially unstable).

Patients with a CUPS status of C or U should be prepared for immediate transport to
definitive care. Consider transport to a pediatric critical care center if available rather
than the nearest hospital. Call for ALS backup if available, provided the time to ALS
backup is considerably less than travel time to the hospital. Do not call for ALS
backup if it will significantly prolong total transport time.

Patients who are potentially unstable should be transported promptly. EMTs may
complete focused history questions and the detailed physical exam on the way if there
is time. They may need to revise CUPS assessment and interventions based on their
Shock · 14
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Shock · 15
findings.

If the child’s condition is stable, the EMTs may continue with a focused history and
detailed physical examination on the scene.
The accompanying table summarizes assessment findings that help determine the CUPS
status.
CUPS Assessment for Pediatric Shock
Assessment
Critical
(Late shock)
Unstable
(Early shock)
Potentially unstable
(Mechanism for shock)
Stab
Pulse rate
Very fast or slow
Fast
Normal
Normal
Pulse
strength
Weak central pulse,
absent peripheral
pulse
Normal central
pulse, weak
peripheral pulse
Normal
Normal
Capill refill
More then 5 seconds 3–5 seconds
2–3 seconds
2–3 secon
BP
Low
Normal
Normal
Normal
Skin
Very pale, mottled,
or blue; cool
Normal, pale, or
mottled; cool
Normal
Normal
Actions
Immediately open
airway, suction, give
high-concentration
oxygen, assist
ventilation as
needed; control
bleeding, place in
shock position, keep
warm, and transport
Move quickly;
give highconcentration
oxygen, reassess
frequently; control
bleeding, place in
shock position,
keep warm, and
prepare for
transport
If significant mechanism
for shock is found (such as
a fall from a 5th-floor
window), give highconcentration oxygen,
control bleeding,
immobilize, and transport;
begin focused history and
detailed exam during
transport
Move on
focused h
and detail
physical e
if no
mechanis
shock, pre
for routin
transport
Based on CUPS Assessment Table © 1997 N. D. Sanddal, et al. Critical Trauma
Care by the Basic EMT, 4th ed.
Focused History
 Key Point
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During the focused history, EMTs can collect information on key
points they haven’t yet covered. For a stable or potentially unstable
child, detailed background information regarding the child’s illness
or injury can alert EMTs to reassess for shock. For children who
have been assessed as C, U, or P, however, focused history
information should be gathered only if time allows after transport is
underway.
History of blood or fluid loss  Since loss of blood or body fluids is
the most common cause of shock in children, EMTs should begin by
asking whether

the patient had significant bleeding that has
since stopped


there have been frequent or ongoing episodes of
vomiting or diarrhea (be specific—find out how many episodes have
occurred)
the child is not drinking as much as normal

the child is urinating much less than usual (ask
for time of last wet diaper or trip to toilet)

there have been changes in the child’s behavior,
such as irritability or drowsiness
Children who appeared stable throughout the initial assessment should
be considered potentially unstable if there is a significant history of
blood or fluid loss—for example, enough bleeding to soak through
the child’s clothing, or more than ten episodes of vomiting or
diarrhea. The findings listed above should be considered especially
serious if two or more are combined; that is, if a child has had
repeated diarrhea as well as poor fluid intake. Note also that infants
and young toddlers are at particular risk when they lose blood or
fluids, since their total blood volume is small.
 Enrichment point
Blood volume in infants: A typical one-year-old has approximately 800 ml (26 oz) of
total blood volume—about the same volume of fluid contained in two cans of soda.
A one-year-old who has lost a cup of blood has lost almost a third of the total blood
volume. EMTs must keep this in mind when evaluating the seriousness of blood or
fluid loss. Injuries that would be considered minor in an adult, such as lacerations to
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Shock · 17
the face and scalp that bleed freely, can cause shock in an infant.
Possible allergic reaction  If there is no history of blood or fluid loss, EMTs should
ask whether the child may have been bitten or stung by an insect, received a
medication, or eaten a food to which the child is allergic.
If so, find out whether the child has had any allergic reaction to the same substance in
the past. Also ask if the child was admitted to the hospital when these symptoms
occurred.
EMTs should consider the child potentially unstable if there is a positive history for
any allergic reaction. Prepare for immediate transport. Management actions are
described in the accompanying box.
Managing a Serious Allergic Reaction
Although rare, a serious allergic reaction can be fatal, so
it is important for EMTs to recognize it quickly and
begin prompt interventions.
Signs of a serious allergic reaction:
 swelling around the lips and tongue
 wheezing, difficulty breathing
 hoarseness or stridor
 signs of early or late shock
 a reddish, itchy rash covering a large area and
spreading rapidly away from the site of a bite, sting,
or injection
Interventions for a serious allergic reaction:
 frequently reassess circulatory findings
 treat for possible shock—give high-concentration
oxygen, elevate legs, keep warm
 prepare for rapid transport (consider ALS backup
for long transport times)
 administer epinephrine using an automatic injector,
such as an Epi-Pen or ANA-Kit (consult medical
control for dosing information and protocols)
History of heart problems  To find out whether
TRIPP 2.0
the child may have heart problems that could lead
to shock, EMTs should ask whether the child has
had heart surgery or has ever been admitted to the
hospital with heart problems, such as a very fast or
slow heart rate. If so, EMTs should consider the
child potentially unstable and watch for signs of
early shock, reassessing circulatory findings every
five or ten minutes throughout transport.
Detailed Physical Examination
General strategies  The most common physical
findings in shock are (1) signs of significant
trauma and bleeding, and (2) signs of severe
dehydration. Therefore, as EMTs progress through
the examination, they should look for major
lacerations, ecchymoses, and areas of tenderness
anywhere on the body, which may indicate an
injury serious enough to cause internal or external
bleeding. They should also look for signs of
dehydration, which are described by region below.
In addition, there are a few signs associated with
less common types of shock that EMTs may find
during a detailed physical examination. These are
also described in the following sections.
Head  Look for signs of blunt head injury, such
as bruising or swelling. Also look for large
lacerations, active bleeding, or significant bleeding
that has stopped. Scalp and face lacerations are
more dangerous in infants and toddlers, who have
a small total blood volume, than in older children
and adolescents.
Sunken eyes, dry lips and mouth, and lack of tears
are all signs of severe fluid loss. In infants, the soft
spot at the top of the head may also appear sunken.
Children who show these signs and have a history
of fluid loss should be considered potentially
unstable.
Chest  In the absence of a medical history, a long
scar down the center of the chest over the
Shock · 18
TRIPP 2.0
breastbone could indicate that the patient has
undergone open heart surgery, suggesting a
potential for heart problems.
Abdomen  Look for bruising or swelling and feel
for areas of tenderness, which could indicate blunt
injuries and possible internal bleeding.
 Enrichment point
A young child or infant whose heart is not
pumping well may have an enlarged liver, which
can be felt on the right side of the abdominal area.
Extremities  In children who have serious heart
problems, the legs may swell from buildup of
fluid. This is a very rare condition in younger
children. It is more likely to occur in school-age
children and adolescents.
Skin  If the child has a history of fluid loss, pinch
a fold of skin. If it remains pinched into a fold
(“tented”) when released, the child is seriously
dehydrated.
Check for rashes. A reddish, itchy rash covering a
large area or spreading rapidly away from the site
of a bite, sting, or injection could indicate an
allergic reaction.
Children showing any of these skin signs should be
treated as potentially unstable.
 ENRICHMENT
Types and Mechanisms of Shock
Shock occurs when blood circulation fails. Since the blood carries
oxygen throughout the body, shock causes low blood oxygen levels in
body tissues and organs. There are three reasons why circulation fails.

The most common reason is that there is not enough blood in the
circulatory system. This type of shock, called hypovolemic shock,
Shock · 19
TRIPP 2.0
Shock · 20
happens when the child either (1) loses a significant amount of
blood due to a traumatic injury (also called hemorrhagic shock),
or (2) loses a large amount of other body fluids, usually due to
vomiting or diarrhea, which in turn lowers the overall volume of
blood.

Circulation can also fail when a normal amount of blood must fill
a greater space. This type of shock is called distributive shock. It
occurs when the blood vessels enlarge, lowering pressure
throughout the circulatory system. Distributive shock can be
caused by a severe infection or allergic reaction. More rarely, it
can result from a spinal cord injury.

The least common cause of circulatory failure in children is a
heart problem in which the heart is unable to pump blood
effectively. This type of shock is called cardiogenic shock.
These three types of shock are examined in greater detail in the
following sections.
Hypovolemic shock  The most common cause of shock in children,
hypovolemic (or low volume) shock results from loss of blood or
other body fluids.

Hypovolemic shock develops from loss of body fluids due to
illness or injury. Causes include (1) vomiting or diarrhea, which
can lead to shock in infants in just a few hours; (2) excessive
urination, which can occur when diabetic children develop high
blood sugar levels; (3) severe burns, in which case shock sets in
an hour or more later; and (4) evaporation from breathing and
perspiration in children with significant infections. In infants,
especially when sick or feverish, not drinking for several hours
can also cause shock from dehydration. Hypovolemic shock due
to blood loss is more specifically called hemorrhagic shock, and is
described below.

Hemorrhagic shock is a type of hypovolemic shock that develops
from external or internal bleeding due to traumatic injuries. While
all forms of shock are life threatening, hemorrhagic shock is
particularly dangerous due to the rapid loss of blood volume and
oxygen-carrying red blood cells. Mechanisms likely to cause
hemorrhagic shock include traumatic injuries from high-speed
motor vehicle crashes (as passenger or pedestrian), penetrating
TRIPP 2.0
Shock · 21
wounds, falls from extreme heights, or bicycle handlebar injuries.
Distributive shock  Distributive shock results when blood vessels
enlarge, so that the blood must fill a greater space, causing a drop in
pressure. To visualize this, think of how water, flowing from a
narrow stream into a pond, loses force as it enters the larger area. In
the body, blood pressure falls in a similar manner as the blood vessels
enlarge.
There are three types of distributive shock, depending on the
mechanism that causes them.

Septic shock is caused by a bloodstream infection. Children who
have conditions that lower their resistance to infection are at
higher risk for this type of shock. Such conditions include sickle
cell anemia, HIV, and treatment for cancer. Also, children who
have had their spleens removed are at risk for septic shock.
Children experiencing early septic shock may have very strong
(“bounding”) pulses, warm skin, a fast pulse rate, and a high
fever. They may also have a blotchy rash.

Anaphylactic shock is caused by a severe allergic reaction to a bee
sting or insect bite, food, or medication. The child may have
swelling at the point where a sting or injection occurred, as well
as swelling of the mouth and tongue, a reddish skin rash (hives),
wheezing, and signs of respiratory distress.

Neurogenic shock, the least common form of distributive shock,
is caused by spinal cord injury. Mechanisms likely to cause
neurogenic shock include high-speed motor vehicle crashes (as
passenger or pedestrian) or falls from extreme heights. In
neurogenic shock, a child may have slow pulses together with
skin that is warm, rather than cool. Inability to feel or move the
extremities is likely. Which limbs are affected (arms only, legs
only, or all extremities) depends on the location of the spinal
damage.
Cardiogenic shock  This type of shock occurs when the heart is
unable to pump blood efficiently. Because children generally have
healthy heart muscles, they rarely experience cardiogenic shock,
which is one of the most common types of shock seen in adults.
However, cardiogenic shock will occasionally result when traumatic
injury to the chest causes bruising of the heart or bleeding into the sac
TRIPP 2.0
Shock · 22
surrounding the heart. Medical causes of cardiogenic shock include
heart failure due to a very slow or very fast heart rate, an infection
that weakens the heart muscle, or heart disease from birth defects.
Signs of cardiogenic shock include respiratory distress and wet,
gurgling breath sounds from fluid in the lungs. The skin is often cool
and moist or clammy, unlike other forms of shock in which it is
typically dry. Infants and toddlers will frequently have an enlarged
liver, which arises because the heart’s inefficient pumping allows
blood to back up in the large veins.
 BARRIERS TO LEARNING
Factors that might interfere with EMTs’ assessment and management
of pediatric shock include their relatively infrequent exposure to such
cases, so that they may not easily recognize the signs of shock in
children; lack of practice using specialized techniques to assess
circulation in children; and failure to understand the importance of
aggressively managing early shock whenever possible.
 PRACTICE SESSIONS
To help EMTs develop speed and confidence in recognizing and
treating shock in children, you may arrange for opportunities that will
allow them to practice the necessary skills.

EMTs can make presentations about injury prevention and proper
use of the emergency medical services system during school
visits. During these visits, they should practice checking pulse
rate, capillary refill time, peripheral and central pulses, and blood
pressure on the children. This can also help to make the children
less fearful of these techniques during an emergency. Reward the
children with stickers to make the experience enjoyable.

Arrange for EMTs to spend time in a pediatric emergency
department or pediatric intensive care unit, as this will teach them
a great deal about recognizing shock in pediatric patients.
 REFERENCES
TRIPP 2.0
Shock · 23
Core
Barren, Jill M. “Shock and Hypotension.” In Prehospital Care of Pediatric Emergencies,
edited by J. S. Seidel and D. P. Henderson. Sudbury, MA: Jones & Bartlett, 1997, 27–31.
Chameides, L., and M. F. Hazinski, eds. Textbook of Pediatric Advanced Life Support.
Dallas: American Heart Association, 1994.
 See “Recognition of Respiratory Failure and Shock,” 2-4 to 2-7.
Eichelberger, Martin R., Jane W. Ball, Geraldine L. Pratsch, and John R. Clark. Pediatric
Emergencies: A Manual for Prehospital Care Providers. 2d ed. Upper Saddle River, NJ:
Prentice Hall, 1998. The following chapters contain information specific to shock:
 “General Pediatric Assessment: Physical Examination and Interpretation of Findings—
Circulatory Assessment,” 40–42.
 “Pediatric Trauma Assessment: Initial Assessment—Circulation,” 149–152.
 “Medical Emergencies: Dehydration,” 120–123.
 “Medical Emergencies: Sepsis and Septic Shock,” 118–120.
 “Medical Emergencies: Congenital Heart Defects,” 129–131.
Guerin, R. T., and R. Elling. Prehospital Pediatric Care Course: A Continuing Education
Course for EMTs. Instructor Manual and Student Workbook. New York State Department
of Health EMS Program, 1990. See the following chapters:
 “Pediatric Trauma,” 89–92.
 “Medical Emergencies,” 67–68.
Simon, Joseph, and A. T. Goldberg. Prehospital Pediatric Life Support. St. Louis, MO:
C. V. Mosby, 1989.
 See “Shock,” 34–41.
EMSC Resources
The following is a sample listing of products described in the EMSC Products Catalog.
You may obtain these items by contacting the EMSC Program of the National Maternal and
Child Health Clearinghouse at 703/356-1964 or by e-mail nmchc@circsol.com.
Item 0217. Pediatric Prehospital Care Course: Instructor’s Manual. (WA) Lesson 3:
“Shock and Shock Management,” 1–6.
Item 0279. Prehospital Pediatric Care Course: A Continuing Education Course for EMTs.
Instructor Outline. (NY) Lesson 6: “Pediatric Trauma,” 119–137.
Item 0352. Prehospital Pediatric Care Instructor Guidelines. Module Three: Shock and
Shock Management, Answer Key. (UT)
TRIPP 2.0
Shock · 24
Item 0353. Prehospital Pediatric Care Provider Manual. Module Three: Shock and Shock
Management. (UT)
Item 0354. Utah EMSC Project. Pediatric Shock. Videotape. (UT)
Item 0472. New Jersey EMSC Prehospital Pediatric Emergency Care: A Course for the
EMT. Basic Instructors Manual. (NJ) Chapter 5: “Shock,” 1–11.
Enrichment
Chameides, L., and M. F. Hazinski, eds. Textbook of Pediatric Advanced Life Support.
Dallas: American Heart Association, 1994. See the following chapters:
 “Vascular Access,” 5-1 to 5-17.
 “Fluid Therapy and Medication,” 6-1 to 6-18.
Silverman, B. K., ed. APLS: The Pediatric Emergency Medicine Course. 2d ed. Elk Grove
Village, IL: American Academy of Pediatrics and Dallas: American College of Emergency
Physicians, 1993. See the following chapters:
 “Cardiovascular Emergencies,” 39–55.
 “Traumatic Emergencies,” 59–84.
TRIPP 2.0
Shock · 25
 TRIPP HANDOUT
Key Points: Pediatric Shock (Hypoperfusion)
 The two main causes of shock in children are (1)
bleeding from traumatic injuries, and (2) body
fluid loss from vomiting and diarrhea.
 Less common causes of shock in children include
blood infections, severe allergic reactions, serious
burns, spinal cord damage, heart problems, and
diabetes.
 Children in early shock often appear well, with a
strong central pulse and a good first impression.
Initial assessment findings for early shock include
a fast pulse rate and abnormal skin findings
(bluish color, cool temperature, and slow capillary
refill time), weak peripheral pulses, and
sometimes a slight change in mental status.
 When children progress to late shock, their
condition worsens suddenly and rapidly.
Assessment findings for late shock include a poor
first impression, decreased responsiveness, poor
muscle tone, airway and breathing problems, and
a weak central pulse. (In children, a weak central
pulse is associated with low blood pressure.)
Peripheral pulses are absent. The central pulse
rate may be very fast or slow, and capillary refill
time is greatly delayed (longer than five seconds).
 Blood pressure need not be measured in children
aged three years or younger, as a strong central
pulse is evidence of adequate blood pressure at
this age. Use a blood pressure cuff only on
children older than three years.
 Assess carefully for early shock if the child’s
history includes any of the following: significant
loss of blood or other body fluids; serious
infection; allergic reactions to foods, medications,
or insect stings; severe burns; spinal cord injury;
heart problems; or diabetes.
 To treat a child who shows signs of early shock,
give high-concentration oxygen, control external
bleeding, place the child in shock position (legs
slightly elevated), and keep the child warm.
Consider ALS backup and transport to a pediatric
critical care center.
 To treat a child who shows signs of late shock,
you may need to open and maintain the airway.
Give high-concentration oxygen (using assisted
ventilation if needed), control external bleeding,
place the child in shock position, and keep the
child warm. Children in late shock are likely to
require ALS backup and transport to a pediatric
critical care center.
TRIPP 2.0
Shock · 26
 TRIPP HANDOUT
CUPS Assessment for Pediatric Shock
Assessment
Critical
(Late shock)
Unstable
(Early shock)
Potentially unstable
(Mechanism for shock)
Stable
Pulse rate
Very fast or slow
Fast
Normal
Normal
Pulse
strength
Weak central pulse,
absent peripheral
pulse
Normal central
pulse, weak
peripheral pulse
Normal
Normal
Capill refill
More then 5 seconds 3–5 seconds
2–3 seconds
2–3 seconds
BP
Low
Normal
Normal
Normal
Skin
Very pale, mottled,
or blue; cool
Normal, pale, or
mottled; cool
Normal
Normal
Actions
Immediately open
airway, suction, give
high-concentration
oxygen, assist
ventilation as
needed; control
bleeding, place in
shock position, keep
warm, and transport
Move quickly;
give highconcentration
oxygen, reassess
frequently; control
bleeding, place in
shock position,
keep warm, and
prepare for
transport
If significant mechanism
for shock is found (such as
a fall from a 5th-floor
window) give highconcentration oxygen,
control bleeding,
immobilize, and transport;
begin focused history and
detailed exam during
transport
Move on to
focused history
and detailed
physical exam;
if no
mechanism for
shock, prepare
for routine
transport
Based on CUPS Assessment Table © 1997 N. D. Sanddal, et al. Critical Trauma Care by the Basic EMT, 4th ed.
TRIPP 2.0
Shock · 27
 TRIPP HANDOUT
Assessment Findings for Pediatric Shock
NOTE: Children in early or late shock may present with some, but not all, of the assessment
findings below. Children should be treated for shock if several of the listed assessment findings
are present.
Assessment
Normal
Early
Late
Mental status
Alert, responsive
Anxious, agitated
Abnormal (V, P, U)
Muscle tone/
Body position
Normal, able to sit
Normal or somewhat
limp
Limp
Airway
Open
Open or maintained
with positioning
Requires positioning;
may need adjunct
Breathing rate
Normal
Fast
Very fast or slow
Breathing
effort
Normal
Slightly increased
Usually increased;
sometimes decreased
Pulse rate
Normal
Fast
Very fast or slow
Central pulse
Normal
Normal
Weak
Periph pulse
Normal
Weak
Absent
Skin color
(extremities)
Normal
Normal, pale, or
mottled
Very pale, mottled,
or blue
Skin temp
Normal
Cool
Cool
Capill refill
2–3 seconds
3–5 seconds
More than 5 seconds
BP*
Normal for age
Normal for age
Low for age
Actions
Work at moderate
pace through
focused history and
detailed physical
exam; be prepared
to reassess
condition
Move quickly; give
high-concentration
oxygen, control
bleeding, place in
shock position, and
keep warm; reassess
frequently and prepare
for transport
Immediately open
airway, suction,
give high-concentration
oxygen, assist
ventilation as needed;
control bleeding, place
in shock position, keep
warm, and transport
*In children aged three years or younger, a strong central pulse is a good indication of adequate blood
pressure.
TRIPP 2.0
Shock · 28
 TRIPP HANDOUT
Managing a Serious Allergic Reaction
Although rare, a serious allergic reaction can be fatal, so it is important for
you to recognize it quickly and begin prompt interventions. The following
information summarizes history, assessment findings, and appropriate
interventions for allergic reactions.
History (may not be present in all cases)


exposure to an insect bite or sting, medication, or food to which the
child is allergic (such as peanut oil)
prior hospitalization for severe allergic reaction
Physical findings





swelling around the lips and tongue
wheezing, difficulty breathing
hoarseness or stridor
evidence of early or late shock
a reddish, itchy rash covering a large area or spreading rapidly away
from the site of a bite, sting, or injection
Interventions




frequently reassess circulatory findings
treat for possible shock—give high-concentration oxygen, elevate legs,
keep warm
prepare for rapid transport (request ALS backup for long transport
times)
administer epinephrine using an automatic injector, such as an Epi-Pen
or ANA-Kit (confirm dosing information and protocols with medical
control)
TRIPP 2.0
Shock · 29
 TRIPP HANDOUT
Pediatric Pulse Rates
Age
Low
High
Infant (birth–1 year)
100
160
Toddler (1–3 years)
90
150
Preschooler (3–6 years)
80
140
School-age (6–12 years)
70
120
Adolescent (12–18 years)
60
100
Pulse rates for a child who is sleeping may be 10 percent lower than the low
rate listed.
Low-Normal Pediatric Systolic Blood Pressure
Age*
Low Normal
Infant (birth–1 year)
greater than 60*
Toddler (1–3 years)
greater than 70*
Preschooler (3–6 years)
greater than 75
School-age (6–12 years)
greater than 80
Adolescent (12–18 years)
greater than 90
*Note: In infants and children aged three years or younger, the presence of a
strong central pulse should be substituted for a blood pressure reading.