Code 3 Workshop

Paramedic Education
Home/All lessons/Medical/Pediatric Septic Shock in the Field
Lesson

Pediatric Septic Shock in the Field

12 min Medical Skip to quiz

Objective: Spot pediatric septic shock before hypotension, give oxygen and access, reassess after every fluid bolus, and do not wait for an adult BP number.

Why This Is Hard

The BP is 90 and the parent says they are sleepy. Adult hypotension cutoffs do not apply. PALS: compensated shock is tachycardia, delayed cap refill, cool extremities (or warm/flash refill in distributive shock), and altered mentation with a still-recordable BP. Hypotension is late. SSC pediatric guidance and PALS both want early recognition and repeated small-to-moderate fluid challenges with lung and perfusion checks — not a 30 mL/kg slam “because sepsis.”

On this truck
  • Work of breathing, mental status, cap refill, pulse quality, and urine history beat a single BP.
  • Oxygen. Check glucose. Access (IV/IO). Fever is a clue, not a requirement — immunocompromised kids can be cool and septic.
  • Fluid is a bolus you reassess, not a bag you bury. If rales, hepatomegaly, or worsening distress appear, stop and use your cardiogenic/pressors pathway per protocol.

Street Sequence

  1. From the door: tone, work of breathing, skin. If they look toxic, this is ALS and a short scene.
  2. Airway/oxygen. Glucose. Monitor. Expose for petechiae/purpura (meningococcemia is a destination and isolation problem too).
  3. Access. First isotonic bolus per PALS/protocol (commonly 10–20 mL/kg teaching range) — then reassess lungs, liver, perfusion.
  4. If still shocked after authorized fluids: vasoactive pathway and pediatric-capable ED/PICU destination. Do not hunt for a “source” on scene.
  5. Notify early. Sepsis is a hospital clock; your job is recognition and the first hour of support.

Field Rules (Education)

  • Compensated vs hypotensive: a “normal” BP does not clear a mottled, tachycardic, listless toddler.
  • Bolus then look: PALS-style teaching is repeated crystalloid with reassessment. Fluid-refractory shock needs pressors per protocol, not endless volume.
  • Cardiogenic mimic: myocarditis and cardiomyopathy look like sepsis. Worsening distress or a big liver after a bolus is a stop sign.
  • Antibiotics: some EMS systems give them; most do not. Do not delay transport to “complete a workup.”
Say out loud
  • Pediatric shock — not waiting for adult hypotension
  • Glucose, oxygen, access
  • Bolus __ mL/kg, then reassess lungs and perfusion
  • Pediatric-capable destination

Field Pitfalls

  • Calling a listless febrile infant “just a virus” because the BP is 88.
  • Giving an adult-sized fluid dump without reassessing the lungs.
  • Staying on scene for a second tympanic temperature.

Practice

60-second drill

4-year-old, fever, cap refill 4 seconds, sleepy, BP 92/60. First four actions. After 20 mL/kg they crackle and the liver edge is down. Next sentence.

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

Street decisions from this lesson only. 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:
← Hypoglycemia Refusal & Capacity Stroke Mimics: Still Protect the Clock →