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Neonates With Shock. Very young infants (<28 days) can present with shock
from a variety of causes, and are mentioned separately here due to challenges in
shock recognition and differences in treatment in this vulnerable population.
Neonates with shock can decompensate very rapidly. They certainly can present
in a similar fashion to older children with the signs and symptoms described
above, but also can present in a decompensated state with hypothermia, apnea,
and bradycardia. A broad differential diagnosis should be maintained including
sepsis, undiagnosed congenital heart disease (Chapter 73 Septic-Appearing Infant
), metabolic disease, and trauma (accidental or nonaccidental).

PRINCIPLES OF SHOCK MANAGEMENT
The mainstays of shock treatment are rapid recognition of the compensated or
uncompensated shock state, rapid reversal of shock, and identification and
treatment of the underlying etiology of shock. Important aspects of shock reversal
include assessment of airway patency and adequacy of breathing, provision of
supplemental oxygen, establishment of vascular access, restoration of the
circulating blood volume, support of the cardiac and vascular system with
appropriate vasoactive agents when necessary, and frequent reassessment of the
patient’s response. The management strategies discussed in the following sections
apply to all shock types, with additional discussion at the end of the section for
type-specific management recommendations.

Vascular Access
Intravenous (IV) access should be established immediately, preferably with two
large-bore peripheral IVs. If peripheral IV access cannot be obtained within the
first 5 minutes of shock recognition, intraosseous access should be established
until more definitive vascular access can be obtained. Central venous access
should be strongly considered if the patient has fluid-refractory shock (e.g.,
remains in shock despite rapid administration of at least 60 mL/kg of fluid
resuscitation) or if vasoactive agents are initiated. For those in refractory shock,
central venous access also allows for monitoring of important goal-directed

therapy targets, such as ScvO2 . Arterial blood pressure monitoring with an intraarterial catheter is also recommended for children in fluid-refractory shock. An
arterial catheter provides continuous monitoring of the arterial blood pressure to
aid in titration of fluid resuscitation and vasoactive infusions and facilitates
monitoring of arterial blood gases to follow acidosis and lactate to guide
resuscitation. Although central venous access and arterial access are more
commonly established following transfer to definitive care in the PICU, advanced
vascular access could be obtained in the ED setting if immediate transfer to