9f2. Responding to Distributive Shock, Pediatric Advanced Life Support (PALS) (2018) HD

This lesson discusses responding to distributive shock. The three types of distributive shock discussed are septic, anaphylactic and neurogenic. The approaches are different, according to the type of distributive shock, and those differences are highlighted within the lesson. There is also information given about the administration of medicines and broader evaluation. "The initial management of distributive shock is to increase intravascular volume. The intent is to provide enough volume to overcome the inappropriate redistribution of existing volume. To do so, administer 20 mL/kg of fluid as a bolus over 5 to 10 minutes and repeat as needed. Beyond initial management, therapy is tailored to the cause of the distributive shock. In septic shock, aggressive fluid management is generally necessary. Broad-spectrum intravenous antibiotics are a key intervention and should be administered as soon as possible. In addition, a stress dose of hydrocortisone (especially with adrenal insufficiency) and vasopressors may be needed to support blood pressure. After fluid resuscitation, vasopressors are given if needed and according to the type of septic shock. Normotensive individuals are usually given dopamine; warm shock is treated with norepinephrine; and cold shock is treated with epinephrine. Transfusing packed red blood cells to bring hemoglobin above 10 g/dL treats decreased oxygen carrying capacity. As blood cultures return, focus antibiotic therapy to the particular microbe and its resistance patterns. For anaphylactic shock, intramuscular epinephrine is the first and most important treatment. In severe cases, a second dose of epinephrine may be needed or intravenous administration may be required. Crystalloid fluid can be administered judiciously. Remember that in anaphylactic shock, capillary permeability may increase considerably. Thus, while it is important to support blood pressure overall, there is significant likelihood that third spacing and pulmonary edema will occur. Antihistamines and corticosteroids can also blunt the anaphylactic response. If breathing challenges arise, consider albuterol use to achieve bronchodilation. In very severe cases of anaphylactic shock, a continuous epinephrine infusion in the Neonatal Intensive Care Unit, or NICU, or Pediatric Intensive Care Unit, or PICU, may be required. Neurogenic shock is clinically challenging because often there is limited ability to correct the insult. Injury to the autonomic pathways in the spinal cord results in decreased systemic vascular resistance and hypotension. An inappropriately low pulse or bradycardia is a clinical sign of neurogenic shock. Therefore, treatment is focused on fluids first. Administer 20 mL/kg bolus over 5 to 10 minutes; then reassess the individual for a response. If hypotension does not respond to fluid resuscitation, vasopressors are needed. This resuscitation should be done in conjunction with a broader neurological evaluation and treatment pl