Pediatric emergency medicine trisk 0290 0290

Stress-Dose Corticosteroids. For patients with septic shock, absolute or
relative adrenal insufficiency is a common condition that is frequently associated
with refractory shock. Stress doses of hydrocortisone (50 to 100 mg/m2/day) are
recommended for those with risk factors for adrenal insufficiency (e.g., septic
shock with purpura, prior steroid therapy for chronic illness, known pituitary or
adrenal abnormalities). Even patients without risk factors may develop critical
illness–related corticosteroid insufficiency with an inadequate adrenal response
and, although evidence for a clinical benefit is not clear, stress-dose
hydrocortisone is currently recommended for children with fluid-refractory,
catecholamine-resistant shock without a reversible etiology pending further data
from clinical trials.
ECMO. ECMO has been used to support neonates and children with refractory
septic shock with reported survival rates of ∼70% for newborns and ∼50% for
older children. One study suggests that central cannulation via sternotomy may
achieve survival rates of 74% for refractory septic shock. In cardiogenic shock
due to myocarditis, survival rates of 70% have been reported following ECMO.
Although counterintuitive, due to the need for systemic anticoagulation, ECMO
has also been used successfully in hemorrhagic shock in small series. In most
cases of refractory shock, venoarterial ECMO is preferred over venovenous due
to the presence of hemodynamic instability. Given the risk of ECMO-related
complications, the optimal timing for ECMO cannulation remains unclear.

CONSIDERATIONS FOR INTENSIVE CARE AND TRANSPORT
After initial resuscitation in the ED, ongoing management of children with shock
should be transitioned to clinicians with the appropriate critical care and trauma
expertise in a setting that has the necessary resources to provide pediatric
intensive care. Individuals requiring significant fluid resuscitation, vasoactive
infusions, noninvasive/invasive mechanical ventilation, or high risk for recurrent
hemorrhage should be considered for admission to a PICU. Children with shock
who present to facilities without the necessary resources to treat shock-associated
organ dysfunction (e.g., acute kidney injury requiring dialysis) following the

initial resuscitation period should undergo timely transfer to an appropriate
facility once cardiopulmonary stability has been achieved. Use of a pediatric
specialized team is associated with improved patient survival and fewer adverse
effects during transport. Thus, the use of pediatric specialized teams for transport
of children with shock is recommended whenever it is available.

OUTCOMES