Shock/Hypotension (medical)

Assessment

Pediatric Pearls: Signs & Symptoms: Differential: 
□ Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg 
□ Initial NS bolus is 20cc/kg		□ Restlessness, confusion, weakness 
□ Syncope 
□ Tachycardia 
□ Diaphoresis 
□ Pale, cool, clammy skin 
□ Delayed capillary refill 
□ Coffee-ground emesis 
□ Tarry stools 		□ Infection/Sepsis 
□ Dehydration 
□ Vomiting 
□ Diarrhea 
□ Congenital heart disease 
□ Medication or Toxin 
□ Anaphylaxis 
□ Cardiac Failure (myocarditis) 
□ Pericardial effusion

Clinical Management Options

EMT-B
• Oxygen, target SpO2 92 – 96% 
• Blood glucose assessment
• Keep the patient warm 
Paramedic
• Vascular access 
• Monitor ECG and ETCO2
• These fluid boluses are for volume depletion – NOT for active bleeding. 
• Pediatric: Isotonic Crystalloid bolus 20 ml/kg may repeat 10 ml/kg bolus x 2 PRN 
• Adult non-cardiac: Isotonic Crystalloid 500-1000 ml bolus, may repeat up to 2 liters 
• Adult Cardiac: Isotonic Crystalloid 250-500 ml bolus, may repeat up to 1 liter 
• Push Dose Epinephrine for hypotension not improved with fluid bolus
Consult Online Medical Control as Needed

Pearls

  • Adult hypotension can be defined as a systolic blood pressure of < 90 mmHg or MAP < 60 and signs or symptoms of hypoperfusion – altered mental status, increased respirations, tachycardia, poor pulses, skin changes.
  • ETCO2 is often low in shock. ETCO2 <25mmHg is concerning 
  • Consider all possible causes of shock and treat per appropriate protocols 
  • Patients should always have adequate intravascular fluid volume prior to the use of vasopressors-> give fluid if you believe they do not have enough intravascular fluid volume. 
  • MAP calculation = [(2 x diastolic) + systolic] divided by 3 
  • Isotonic Crystalloid should be avoided in patients in whom hemorrhage is suspected. 
  • Note that intubating hypotensive patients can cause them to reduce their blood pressure further and cause sudden cardiac arrest. It is appropriate to resuscitate with fluids prior to obtaining an advanced airway when possible.