Pediatric Shock

Shock is oxygen delivery that falls short of what the body needs. In children, heart rate is the main lever. The heart speeds up to push more blood out, so a child can hold a normal blood pressure while perfusion is already failing. Your job is to catch compensated shock (normal BP, poor perfusion) before it becomes decompensated shock (hypotension).

Why Kids Are Different

• Heart rate compensates: a small heart moves only so much blood per beat. Tachycardia is the early fix for volume loss or low output.
• Vasoconstriction masks loss: the pipes clamp down at the periphery and keep central pressures near normal. That holds until the reserve runs out.
• Small size, large surface area: infants lose water and heat fast through the skin. Vomiting and diarrhea make it worse.
• Late signs are abrupt: hypotension often shows up only after a sudden fall. Bradycardia with poor perfusion is a pre-arrest sign.

Pediatric arrest is most often respiratory in origin. Use the cardiac arrest page for that pathway.

One vital sign won't tell you. Read the trend across several signs. Compare the child with their own baseline and age norms (see vital signs by age).

Age-Specific Presentation

• Neonate (0–28 days): poor feeding, lethargy, tachypnea, gray color, and a weak femoral pulse. Keep sepsis and ductal-dependent congenital heart disease on the list.
• Infant (1–12 months): irritability, poor feeding, sunken fontanelle and fewer wet diapers.
• Child (1–12 years): thirst, lethargy, cool extremities, abdominal pain or vomiting, and less urine.
• Adolescent (13–18 years): hypotension shows up later, then drops fast. Use adult shock signs and adult thresholds.

Cold vs Warm Shock

Warm (distributive) shock is more common in older kids and adults. It still happens in children, often as septic shock. Kids don't always fit one pattern, so judge the trend.

You don't need capillary refill over 2 s to diagnose shock. A warm child with flash refill can still be in shock. Pick the vasoactive drug by clinical picture and local protocol, not by warm or cold alone.

Hypotension Thresholds

• Term neonate: systolic BP below 60 mmHg
• Infant (1–12 months): systolic BP below 70 mmHg
• Child (1–10 years): systolic BP below 70 + (2 × age in years) mmHg
• Above 10 years: systolic BP below 90 mmHg

Under the 2024 Phoenix pediatric criteria, sepsis is suspected infection with a Phoenix score of 2 or more points across the respiratory, cardiovascular, coagulation and neurologic systems. Septic shock adds at least one cardiovascular organ-dysfunction point. That point comes from vasoactive medication count, lactate or age-based mean arterial pressure. The consensus criteria replace the older SIRS-based pediatric definitions.

1. Give isotonic crystalloid: 10–20 mL/kg IV or IO as a push over 5–20 min (Paramedic/RN/CCT, per local protocol). Do not rely on a gravity drip in shock.
2. Reassess after each bolus: HR, capillary refill, mental status, pulses, BP trend, SpO₂, work of breathing and lung exam, and urine output.
3. Repeat as perfusion demands: SSC 2026 supports up to 40–60 mL/kg in the first hour, given as 10–20 mL/kg boluses. Stop when shock resolves or fluid overload develops (crackles, hepatomegaly, rising oxygen need).
4. Hemorrhage: control external bleeding, and involve surgery for intra-abdominal or pelvic bleeding. Give blood products early in hemorrhagic shock per the trauma or transfusion protocol. Tranexamic acid and massive transfusion protocol activation are per the trauma protocol; product ratios and any permissive-hypotension target are protocol-dependent, and no fixed blood volume is given here.
5. Treat the cause: antiemetic and oral or IV rehydration plans for gastroenteritis; DKA fluid management per the DKA protocol; burns per burn protocol.

0–5 Minutes

1. Recognize and access: obtain IV or IO access (Paramedic/RN/CCT, per protocol). Check glucose.
2. Draw labs without delay: blood culture, lactate, CBC, BMP and coagulation studies. SSC 2026 recommends measuring lactate as part of the initial evaluation.

Within 1 Hour

1. Give antibiotics: in septic shock, start them as soon as possible, ideally within 1 hour of recognition. SSC 2026 strongly recommends this. Don't wait for culture results. Empiric choice follows local sepsis protocol and risk factors, which may add vancomycin for MRSA or meningitis coverage. Probable sepsis without shock gets a time-limited rapid evaluation first, then antimicrobials as soon as possible, ideally within 3 hours of recognition (conditional recommendation).
2. Give fluid (septic shock with hypotension): 10–20 mL/kg balanced or buffered crystalloid per bolus, reassessing after each. SSC 2026 suggests balanced solutions over 0.9% saline. With ICU access, up to 40–60 mL/kg in the first hour. Without ICU access, up to 40 mL/kg in 10–20 mL/kg boluses over the first hour. Sepsis without hypotension and without ICU access? Don't give boluses. Start maintenance fluids (SSC 2026 strong recommendation).

After Fluid-Refractory Shock

1. Start a vasoactive infusion: epinephrine or norepinephrine. SSC 2026 found insufficient evidence to prefer one over the other, so choose by clinical picture and local protocol. Dopamine is second-line here (see the dopamine page). Start peripherally or IO while central access is placed, and watch the site for extravasation.
2. Add vasopressin or titrate catecholamines: SSC 2026 suggests this when high-dose catecholamines are needed. Vasopressin use in children is PICU specialist practice.
3. Hydrocortisone: give stress-dose hydrocortisone when adrenal insufficiency is suspected or known. SSC 2026 suggests against routine IV hydrocortisone when fluids and vasoactive therapy restore stability.
4. Intubation: if intubation is needed, resuscitate first and have a vasoactive ready. SSC 2026 suggests against etomidate for intubating children with sepsis (conditional recommendation).
5. Escalate: PICU consultation and transfer. Add an inotrope if cardiac dysfunction persists (see the cardiogenic section).

Anaphylactic and Neurogenic Shock

• Anaphylaxis: epinephrine IM 0.01 mg/kg of 1 mg/mL, max 0.3 mg (prepubertal) or 0.5 mg (adolescent), repeat every 5–15 min (Epinephrine 1 mg/mL (IM)). Add a fluid bolus. If it stays refractory, start an epinephrine infusion, per protocol.
• Neurogenic shock: a spinal cord injury opens the pipes wide, often with bradycardia and no tachycardia. Go easy on fluids. Restore perfusion with a vasopressor (norepinephrine or phenylephrine) per protocol.

Cardiogenic Shock

• Myocarditis: a viral illness, then sudden decompensation. Give cautious 5–10 mL/kg boluses and reassess each one. Large volumes can worsen pulmonary edema.
• Inotropes: milrinone or dobutamine, specialist use only (PICU or cardiology). No pediatric dose is established for either (AHA 2025 Part 8 names both with no dose). Add a vasopressor if MAP is low.
• Arrhythmia: SVT is a common cause of shock in infants. Treat the rhythm per the pediatric tachycardia or bradycardia algorithm (Paramedic/RN/CCT, per protocol).
• Post-cardiac-surgery low output: treat with the cardiac team's inotrope and vasoactive plan.

Ductal-Dependent Lesions (Neonate)

1. Consider the diagnosis: if a neonate in shock doesn't respond to fluid and antibiotics, think ductal-dependent heart lesion.
2. Start alprostadil (PGE1): 0.05–0.1 mcg/kg/min IV (or umbilical artery catheter per label); IO only per specialist or protocol when no other access exists. Then reduce to the lowest effective rate (usually 0.01–0.1 mcg/kg/min). Specialist-directed.
3. Monitor for apnea: about 10–12% of neonates with congenital heart defects get apnea on PGE1 (boxed warning), and it is most common under 2 kg at birth. Have airway and ventilation equipment ready before you start.
4. Oxygen: in suspected ductal-dependent lesions, too much oxygen is a trap here. Titrate to avoid hyperoxia. High FiO₂ may promote ductal closure or pulmonary overcirculation in some lesions. Use pre- and post-ductal SpO₂ and specialist advice.

Obstructive Shock

• Tension pneumothorax: needle decompression followed by chest tube, per protocol. Do not wait for a chest X-ray in an unstable child.
• Cardiac tamponade: pericardial drainage by a specialist. Look for muffled heart sounds and distended neck veins.
• Massive pulmonary embolism: rare in children and more often seen with central lines. Specialist decision on thrombolysis.

Pediatric doses come from three sources, in this order. First AHA/AAP 2025, where it states a dose. Then the NASEMSO National Model EMS Clinical Guidelines v3.0 (2022). Then the US label. Where none of them gives a dose, none is shown. No pediatric maximum ever goes above the adult maximum dose (NASEMSO Universal Care Guideline, p. 13). Unless marked labeled, the dose is off-label. Dose on actual body weight, in kg. Calculate mL/hr as dose (mcg/kg/min) × weight (kg) × 60 ÷ concentration (mcg/mL).

• Labs: lactate, glucose, electrolytes, BUN and creatinine, CBC, coagulation studies (DIC is common in septic shock), and blood gas with base deficit. Trend the base deficit on serial gases. Forget the fixed cutoff.
• Disposition: PICU or a pediatric-ready ED. Transfer early. Ideally, move the child before they're on multiple infusions or intubated.

Neonates and Young Infants

• Two shock types can look alike: sepsis and ductal-dependent heart disease. No response to fluid and antibiotics? Consider the second.
• Check glucose early and repeatedly. Use D10W 2 mL/kg for a neonate.
• Neonatal septic shock: ampicillin plus gentamicin or cefotaxime per neonatal protocol. Consider acyclovir when HSV is possible in a febrile or ill neonate. Ceftriaxone is contraindicated in neonates 28 days or younger who need calcium-containing IV solutions.

Adolescents

• Switch point: at 40 kg or more, or beyond the length-based tape, use adult protocols and adult dose maximums. Follow local protocol.

Children With Special Health Care Needs

• Carry the Emergency Information Form: it lists the central line, VP shunt, gastrostomy, tracheostomy and home medications.
• Ask about steroids: long-term or recent steroid use points to adrenal suppression. That changes the fluid and hydrocortisone plan.

Congenital Heart Disease

• Ask about prior surgery: single-ventricle physiology and Fontan circulation don't tolerate hypovolemia or arrhythmia well. Call cardiology early.

• Prepare the drugs: pre-drawn or color-coded bolus syringes; pump programmed in mcg/kg/min with the dosing weight written on the label.
• Choose the destination: the nearest pediatric-ready ED for initial stabilization, or PICU when escalation is expected.
• Restrain on the stretcher: use a size-appropriate restraint. Do not hold the child on a caregiver's lap during transport.
• Vasoactives and airway: a peripheral or IO vasoactive start is acceptable while central access is placed. Watch the site for extravasation. If intubation is needed, resuscitate first and have a vasoactive ready. SSC 2026 suggests against etomidate.
• Keep the child warm: infants lose heat fast. Warm the fluids when feasible.
• Handoff: use a structured format (IMIST-AMBO or MIST) and state the fluids given in mL/kg and the time of each bolus.