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pressure ventilation. Positive pressure ventilation will decrease venous return in a
patient who is already hypovolemic, which could precipitate cardiovascular
collapse. It is therefore prudent to have fluid boluses readily available and
vasoactive agents started or immediately ready to administer during this
transition.

Source Control
While IV access is obtained and fluid resuscitation to reverse shock is
undertaken, early consideration of source control to treat the etiology of shock is
necessary.
Hypovolemic Shock. Hemorrhagic shock should be treated with a combination
of crystalloid and blood product administration, as discussed above. For definitive
treatment, the source of bleeding must be found and controlled. Ultrasound and
computed tomography are important modalities for diagnosis of hemorrhagic
shock. Interventional radiology procedures to find and control sources of bleeding
are also becoming increasingly available in children, though early surgical
consultation is recommended as part of the primary and secondary surveys.
Shock related to hypovolemia from etiologies such as gastroenteritis and
dehydration should primarily be treated with fluid resuscitation. Patients with
gastroenteritis are at risk for ongoing fluid losses and may need prolonged
replacement of fluid losses until symptoms improve. It is important to check
electrolytes in this setting as electrolyte abnormalities, especially abnormalities in
sodium handling, are common.
Cardiogenic Shock. Children with congenital heart disease, cardiomyopathies,
or myocarditis may present with cardiogenic shock. Presence of ductal-dependent
congenital heart disease should be suspected in the neonate or young infant
(typically <2 to 3 weeks of age) presenting in shock. Prostaglandin infusion
should be considered if a ductal-dependent cardiac lesion is suspected. Imaging
with chest radiography and echocardiography may aid in diagnosis and a
pediatric cardiologist should be consulted early in the treatment course. Rapid
transfer to a tertiary care center with a pediatric cardiovascular intensive care unit

should be arranged.
Distributive Shock. The American College of Critical Care Medicine and
Surviving Sepsis Campaign recommends the administration of broad-spectrum
antibiotics within 1 hour of sepsis recognition, and this is a key quality metric for
septic shock treatment. Several adult studies have shown increased mortality with
delays in rapid antibiotic administration in patients with septic shock, and
pediatric evidence demonstrates an association between mortality and progressive
antibiotic administration delays. Initial antibiotic choice should be broad and