CHAPTER 10 ■ SHOCK FRAN BALAMUTH, JULIE C FITZGERALD, SCOTT L WEISS DEFINITION OF SHOCK Normal circulatory function is maintained by a complex interplay between the central pump (heart) and blood flow at the regional level (microcirculation) for the purpose of delivering oxygen and nutrients to tissues and removing metabolic by-products (e.g., carbon dioxide) Shock can be defined as an acute syndrome of cardiovascular insufficiency in which the circulatory system fails to provide adequate oxygen and nutrients to meet the metabolic demands of vital organs, resulting in cellular/metabolic dysfunction This definition recognizes that shock can and does exist without hypotension, especially in children, and that inadequate cellular metabolism of oxygen and nutrients contributes to the clinical manifestations and outcomes observed in patients with shock GOALS OF EMERGENCY THERAPY All physicians who care for ill children will be faced with managing the clinical syndrome of shock Many common childhood illnesses, such as trauma, gastroenteritis, infection, and accidental drug ingestions, can lead to shock Ultimately, without timely medical intervention, the child in shock will follow a common pathway to multiorgan system failure and death Early recognition and appropriate therapy are vital to reduce the morbidity and mortality associated with this serious syndrome The goals of emergency therapy in pediatric shock are threefold: Prompt recognition Shock reversal Transfer to definitive care This chapter is devoted to addressing each of these goals in turn We begin with a discussion of clinical and pathophysiologic considerations in pediatric shock, followed by a description of different etiologic types of shock including hypovolemic, cardiogenic, obstructive, distributive, and dissociative shock ( Fig 10.1 ) The remainder of the chapter is focused on pediatric shock recognition and clinical management, including diagnostic testing, fluid resuscitation, vasoactive agent choice, source control, treatment of refractory shock, and transfer to definitive care Because increasing evidence has accumulated, indicating that care