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general, alteration in mental status, extremity perfusion, and oliguria are early
indicators of shock. Bedside point of care ultrasound (POCUS) is a helpful
adjunctive tool to assess intravascular volume status, myocardial function, and
other clues about the underlying etiology of shock (e.g., pericardial effusion,
pneumothorax) that may be readily available in the ED setting. Findings on
POCUS may help to optimize interventions to correct shock and can be used to
assess patient response to treatment.
Hemorrhagic Shock . Determine by history whether there was possible
trauma, and if so whether it was blunt or penetrating. The provider should also
determine whether any source of bleeding was recognized prior to arrival (e.g.,
hematemesis, hemoptysis, vaginal bleeding, hematochezia). The emergency
provider also needs to have a high index of suspicion for nonaccidental trauma in
a child presenting in shock with no other preceding symptoms.
Trauma or suspected trauma patients should undergo a full trauma evaluation
including the primary and secondary surveys as detailed in Chapter 7 A General
Approach to the Ill or Injured Child .
Careful evaluation for evidence of bleeding including assessment of open
fontanelles, all orifices, and thorough abdominal examination.
POCUS findings: The focused assessment with sonography in trauma (FAST)
examination may identify areas of internal bleeding (e.g., abdominal,
pericardial).
Hypovolemic Shock. Determine if volume loss may be due to decreased intake
or increased output (vomiting, diarrhea). On physical examination, one should
assess the following:
Mental status/level of activity
Sunken fontanelle and/or eyes
Skin turgor
Capillary refill
Urine output
POCUS findings: Ratio of inferior vena cava to aorta (IVC/Ao) <0.8 to 1 in a
spontaneously breathing child, absence of ventricular dilation, normal or

hyperdynamic ventricular function, and decreased aortic blood flow peak
velocity (ΔVpeak ). Fluid responsiveness may be evidenced by >50% respiratory
variation (nonintubated patients) and >20% respiratory variation in the IVC
diameter on longitudinal view. Repeat POCUS examinations during volume
resuscitation can be used to evaluate for changes to the above parameters to