Continued...

Rapid cardiopulmonary assessment and clinical examination of a patient in shock:

The most effective and sensitive physiological monitoring available is, repeated and careful physical examination by an experienced and competent observer. Because the shock can be rapidly fatal, the child must be assessed immediately and comprehensively. In a healthy child, the cardiovascular system has remarkable compensatory capability, so there is generally a stability of blood pressure and only an increase in pulse until there is sudden decompensation, which may lead to precipitous cardiac arrest.

In clinical examination one must note following points very carefully:

• Mental status : Restless, agitated, anxious, progressive lethargy
  
  
• Skin : Temperature, colour, turgor, petechial rash may be present in meningococcemia or disseminated intravascular coagulation.
  
  
• Cardiovascular : By far, the most significant physical findings in septic shock results from autonomic responses to stress. In children tachycardia occurs early. The younger the child, cardiac output is more dependent on heart rate rather than on increase in stroke volume Alteration in blood pressure is a late manifestation of hypovolemia in children, occurring faster in children. Diastolic blood pressure begins to fall early as vascular tone begins to decrease. Systolic Blood pressure is well maintained initially and only begins to fall once hemodynamic compromise is severe. Decreasing blood pressure signifies decompensated stage of shock. In warm phase of septic shock capillary refill time may be normal, however signs of hyperdynamic circulation, widened pulse pressure, hyperdynamic apex beat are important signs. Capillary refill time of more than 5 seconds is always abnormal.
  
  
• Respiratory: Respiratory rate is increased to compensate for metabolic acidosis. Secondly if ARDS is developing, progressive worsening of respiratory distress may occur.
  
  
• Urine output : Oliguria is common leading to anuria. It is important to remember that physical findings will vary according to the stage of shock.
  

Emergency management :
Management of child with septic shock is best started by aggressive goal directed management in the emergency department.

The treatment of septic shock in children is aimed at optimizing perfusion of critical vascular beds and preventing or correcting metabolic abnormalities arising due to cellular hypoperfusion. The ultimate goals are to prevent or reverse the defects in cellular substrate delivery and metabolism and to support entire patient until homoeostasis is restored. For all forms of shock, treating the underlying cause is mandatory. Speed is essential. Delays in making the diagnosis and initiating treatment (fluid resuscitation as well as appropriate antibiotics), as well as suboptimal resuscitation, contribute to the developments of peripheral vascular failure and irreversible defects in oxygen use which can culminate in vital organ dysfunction.

Priorities of treatment
Two major priorities in treatment of septic shock are:

• Rapid assessment of patient's disease process
  
  
• Achievement of cardiopulmonary stability

VIP approach can be used in initial treatment of shock.
V standing for ventilation,
I for infusion and
P for pumping or cardiovascular support

Initial resuscitation of child in shock involves assessment of airway, administration of oxygen and establishment of intravenous access.