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following severe traumatic brain or cervical spine injury (see Chapter 112 Neck
Trauma ).

Dissociative Shock
Dissociative shock is a special category of shock that occurs as a consequence to
a toxic metabolite or drug that severely impairs cellular oxygen delivery or
utilization despite sustained or supranormal tissue perfusion. Examples include
severe anemia, methemoglobinemia, and carbon monoxide poisoning (see
Chapter 102 Toxicologic Emergencies ).

CLINICAL CONSIDERATIONS IN SHOCK RECOGNITION
The early recognition of children with compensated shock is an important clinical
challenge. We focus here primarily on early septic shock recognition, but these
principles can be applied to multiple shock types.

Vital Signs
Important vital sign abnormalities, including fever or hypothermia, tachycardia,
and tachypnea may signal developing septic shock. Because hypotension is a late
finding in pediatric shock, children often present in compensated shock with
tachycardia and abnormal perfusion, but normal blood pressure. However, given
the high prevalence of SIRS in the pediatric emergency setting in patients without
sepsis, as well as the overall rarity of sepsis in children with infectious illness, use
of these vital sign–based criteria alone has proven insufficient to recognize sepsis.
The challenge of identifying the pediatric patient with compensated septic shock
is often described as “finding a needle in a haystack.” As such, there is increasing
interest from hospitals, professional medical societies, and legislative bodies to
put systems in place to improve sepsis recognition. Automated sepsis alert
systems embedded in the electronic medical record are one such mechanism.
Although there is evidence that such alerts, which utilize differing combinations
of history, vital signs, and nursing assessments, can improve the sensitivity of
sepsis recognition, the specificity of such alerts can be substantially increased by

a prompt physician evaluation at the bedside to assess for other clinical signs of
shock. In addition, the impact of these electronic alerts on sepsis
overidentification, antibiotic overuse, and other balancing measures in the
emergency department (ED) needs to be fully evaluated.

History and Physical Examination Findings
In addition to vital signs, there are elements of history and physical examination
that should be assessed to recognize compensated and decompensated shock. In