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Lesson

Pediatric Septic Shock in the Field

12 min Medical Skip to quiz

Objective: Spot pediatric septic shock before the blood pressure falls. Give oxygen, get access, and reassess the lungs after every fluid bolus. Do not give 30 mL/kg all at once, and do not wait for an adult blood-pressure number.

Why this matters

The blood pressure is 90 and the parent says the child is sleepy. Adult hypotension cutoffs do not apply. Compensated shock can be a fast heart rate, slow capillary refill, and cool hands and feet. It can also be warm flushed skin with a flash refill when the blood vessels are too dilated. That pattern is distributive shock. Mental status is off, and a blood pressure may still be recordable. Low blood pressure is late.

First, give oxygen and get access. Check the lungs after every fluid bolus. Do not wait for an adult blood-pressure number. Do not give 30 mL/kg all at once on scene. That 30 mL/kg figure is a hospital 3-hour adult target. It is not a standing field order, and it is not a fluid bolus for a child. Give small aliquots per protocol.

Key points
  • Check work of breathing, mental status, capillary refill, pulse quality, and urine history. One blood-pressure number does not clear shock.
  • Give oxygen. Check glucose. Get IV or IO access. Fever is a clue, not a requirement. A child with a weak immune system can be cool and septic.
  • Give fluid as a bolus, then reassess. Do not empty the bag. If crackles, a large liver, or worse breathing appear, stop and use your cardiogenic or vasopressor pathway.

Clinical sequence

  1. From the door, look at tone, work of breathing, and skin. If the child looks toxic, this is ALS care and a short scene.
  2. Protect the airway and give oxygen. Check glucose. Put them on a monitor. Look for spots that do not fade. Meningococcal disease is also an isolation and destination problem.
  3. Get access. Give the first isotonic bolus your protocol names. A common teaching range is 10 to 20 mL/kg. Then reassess the lungs, the liver, and perfusion. Your protocol owns the volume. Watch the lungs.
  4. If they are still in shock after the fluid you are allowed to give, use the vasopressor pathway if it is written, and go to a pediatric-capable emergency department. Do not hunt for the infection source on scene.
  5. Notify the hospital early. Your job is recognition and the first support.

Teaching points

  • Compensated versus hypotensive. A “normal” blood pressure does not clear a mottled toddler with a fast heart rate who is listless.
  • Reassess after the bolus. Repeat crystalloid only after you look again. Shock that does not respond to the allowed fluid needs a vasopressor per protocol. Do not keep giving volume.
  • Heart-failure mimic. Myocarditis and cardiomyopathy can look like sepsis. If breathing gets worse or the liver edge is lower after a bolus, stop the fluid.
  • Antibiotics. Some EMS systems give them. Most do not. Do not delay transport to finish a workup. Prehospital antibiotics, when they exist, are for shock plus a long transport under a written protocol.
Verbalize
  • This is pediatric shock. I am not waiting for an adult hypotension number.
  • I am checking glucose, giving oxygen, and getting access.
  • I will give a bolus per protocol, then reassess the lungs and perfusion.
  • The destination can take a child.

Common errors

  • Do not call a listless febrile infant “just a virus” because the blood pressure is 88.
  • Do not give an adult-sized fluid bolus without listening to the lungs.
  • Do not stay on scene for a second ear temperature.

Practice

One-minute check

A 4-year-old has a fever, a capillary refill of 4 seconds, and is sleepy. The blood pressure is 92/60. Name the first four actions. After 20 mL/kg the child develops crackles and the liver edge is lower. What do you say next?

Related: Sepsis Recognition, Shock Categories.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. A febrile toddler who is listless with delayed cap refill and a “normal” BP:
2. After an isotonic bolus in a shocked child you should:
3. Worsening distress and an enlarging liver after a fluid bolus suggests:
4. The main prehospital job in pediatric sepsis is:
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