ED Pathway for Evaluation/Treatment of Infants > 28 Days of Age and Children with Suspected Septic Shock

Fluid Refractory Shock

NS > 40-60 ml/kg administered without adequate clinical response

Start, increase dopamine (5-10 mcg/kg/min)
Consider central venous line
Continue fluid boluses until perfusion improves or signs of fluid overload develop

Dopamine Refractory Shock

Shock state persists despite NS > 60 ml/kg, dopamine at 10 mcg/kg/min

COLD SHOCK – BEGIN EPINEPHRINE

Evidence of vasoconstriction on physical examination
Capillary refill > 3 seconds
Diminished peripheral pulses
Mottled, cool extremities

WARM SHOCK – BEGIN NOREPINEPHRINE

Evidence of vasodilatation on physical examination
Brisk capillary refill
Bounding peripheral pulses
Warm, flushed extremities
Wide pulse pressure

ICU Level of Monitoring Required

Airway/Sedation

Ketamine, atropine and fentanyl
Vecuronium or Rocuronium

Monitoring

CR monitor, blood pressure q 15 minutes
Continuous pulse oximetry, ETCO2 if indicated
Central access, monitor CVP
Foley catheter to monitor urine output

Coagulopathy/Bleeding

FFP 10 ml/kg
Maintain hemoglobin, PRBC for target Hb 10g/dL
Platelets if platelet count < 50,000