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Chapter 41

### IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS

#### SEPTIC SHOCK

ESSENTIALS OF DIAGNOSIS

• Evidence of poor end-organ perfusion (altered mental status).

• Hypotension.

• Prolonged capillary refill.

• Abnormal oxygen saturation) with an infectious source.

Initial management is focused on ABCs (see Chapter 10).

##### General Considerations

Systemic inflammatory response syndrome (SIRS) may be provoked by a number of infectious and noninfectious causes. It occurs when at least two of the following criteria are met: fever greater than 38.5°C or less than 36°C; tachycardia or bradycardia for age; tachypnea for age, or leukocytosis or leukopenia (Table 41–1). Sepsis occurs when SIRS is caused by an infectious agent. Septic shock falls at the extreme end of this continuum and results when end-organ perfusion becomes compromised. Failure to correct this imbalance of nutrient delivery with nutrient demand leads to end-organ dysfunction and ultimately end-organ damage. Younger children and those with impaired immune systems are at increased risk of sepsis and rapid progression to shock.

Table 41–1.   Normal pediatric vital signs.
##### Clinical Findings

Most children are classified as having “cold” shock, which occurs with low cardiac output in the setting of high systemic vascular resistance. Signs of cold shock include tachycardia, delayed capillary refill, cool and mottled extremities, and weak peripheral pulses. Unlike adults, children have the ability to increase their heart rate greatly to compensate for poor cardiac output; hypotension may be a late finding of shock. Some children will have “warm” shock, which occurs with high cardiac output and decreased systemic vascular resistance. These children may have flash capillary refill, widened pulse pressure, bounding pulses, and warm extremities. However, in each case, perfusion is not adequate, and evidence of end-organ dysfunction will manifest. Decreased perfusion to the brain leads to irritability and lethargy in infants and younger children, and to altered mental status in older children. Similarly, poor kidney perfusion leads to decreased urine output. During the later stages of fluid resuscitation, evidence of volume overload such as rales, hepatomegaly, peripheral edema may develop.

##### Laboratory Tests/Radiographs

Because tissue perfusion is compromised, a full comprehensive metabolic profile (CMP) with coagulation studies is recommended so that liver and kidney function may be established. Complete blood (cell) count (CBC) with differential may show leukocytosis with neutrophilic predominance in bacterial infections, though infants may have leukopenia in this situation. An initial blood gas with a lactate is important for assessing the degree of hypoperfusion as well as ...

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