Hypovolemic shock is the most common form of shock in children. Recognizing the subtle early signs of shock can be daunting even for experienced emergency physicians. Children can maintain an adequate blood pressure, even in the face of severe blood loss, but other signs of shock will be apparent. Monitoring blood pressure alone to diagnose shock is unreliable in pediatric patients. Signs of shock include tachycardia, cool extremities, capillary refill time longer than 3 s, altered level of consciousness, weak distal pulses, and low urine output. Hypothermia can be a confounding factor, because it also can affect skin perfusion.

The treatment of shock in trauma is based on the same principles as other forms of hypovolemic shock. Crystalloid fluid boluses of 20 mg/kg given over 20 min or less are used to resuscitate the child. If two boluses of crystalloid fail to correct signs of shock, then blood (packed red blood cells) should be given using 10 mL/kg boluses. In small children, the blood bank should hold several aliquots from a single donor unit to minimize the risk of a transfusion reaction.

CARDIAC ARREST Absent pulses in a child with traumatic injuries portends a poor outcome. In children with penetrating chest or abdominal trauma, a resuscitative thoracotomy can be lifesaving if vital signs were recently lost. In children with traumatic arrest from blunt trauma, the outcome is always death. 9 Standard advanced cardiac life-support algorithms are followed, but most commonly injured children will have asystole or pulseless electrical activity. Early administration of blood products should be used and any identified injuries treated.

CARDIAC TAMPONADE This condition is rare in children. Most commonly it results from penetrating trauma. Beck's triad consists of hypotension, muffled heart sounds, and jugular venous distention. Diagnosis can be confirmed by echocardiography prior to treatment. Initial fluid boluses may be temporizing, but pericardiocentesis and resuscitative thoracotomy can be lifesaving.

VASCULAR ACCESS Achieving vascular access is one of the most difficult tasks in an injured child. In an adult patient, "two large bore" intravenous lines are placed; in a child, placing a single functioning intravenous line is often considered a success. Ideally two lines are placed so that blood and medications or fluids can be given simultaneously. Practically, a functioning intravenous line is all that may be readily achieved, and is usually adequate. Consideration should be given to early intraosseous line placement in a severely injured child, because any fluids, medications, or blood products can be given through this line. The femoral vein is the next easiest site because of the identifiable landmarks and the relative ease of the procedure compared with other central venous lines in children (see Chap 17,

"Vascular Access").

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