following severe traumatic brain or cervical spine injury (see Chapter 112 Neck Trauma ) Dissociative Shock Dissociative shock is a special category of shock that occurs as a consequence to a toxic metabolite or drug that severely impairs cellular oxygen delivery or utilization despite sustained or supranormal tissue perfusion Examples include severe anemia, methemoglobinemia, and carbon monoxide poisoning (see Chapter 102 Toxicologic Emergencies ) CLINICAL CONSIDERATIONS IN SHOCK RECOGNITION The early recognition of children with compensated shock is an important clinical challenge We focus here primarily on early septic shock recognition, but these principles can be applied to multiple shock types Vital Signs Important vital sign abnormalities, including fever or hypothermia, tachycardia, and tachypnea may signal developing septic shock Because hypotension is a late finding in pediatric shock, children often present in compensated shock with tachycardia and abnormal perfusion, but normal blood pressure However, given the high prevalence of SIRS in the pediatric emergency setting in patients without sepsis, as well as the overall rarity of sepsis in children with infectious illness, use of these vital sign–based criteria alone has proven insufficient to recognize sepsis The challenge of identifying the pediatric patient with compensated septic shock is often described as “finding a needle in a haystack.” As such, there is increasing interest from hospitals, professional medical societies, and legislative bodies to put systems in place to improve sepsis recognition Automated sepsis alert systems embedded in the electronic medical record are one such mechanism Although there is evidence that such alerts, which utilize differing combinations of history, vital signs, and nursing assessments, can improve the sensitivity of sepsis recognition, the specificity of such alerts can be substantially increased by a prompt physician evaluation at the bedside to assess for other clinical signs of shock In addition, the impact of these electronic alerts on sepsis overidentification, antibiotic overuse, and other balancing measures in the emergency department (ED) needs to be fully evaluated History and Physical Examination Findings In addition to vital signs, there are elements of history and physical examination that should be assessed to recognize compensated and decompensated shock In