general, alteration in mental status, extremity perfusion, and oliguria are early indicators of shock Bedside point of care ultrasound (POCUS) is a helpful adjunctive tool to assess intravascular volume status, myocardial function, and other clues about the underlying etiology of shock (e.g., pericardial effusion, pneumothorax) that may be readily available in the ED setting Findings on POCUS may help to optimize interventions to correct shock and can be used to assess patient response to treatment Hemorrhagic Shock Determine by history whether there was possible trauma, and if so whether it was blunt or penetrating The provider should also determine whether any source of bleeding was recognized prior to arrival (e.g., hematemesis, hemoptysis, vaginal bleeding, hematochezia) The emergency provider also needs to have a high index of suspicion for nonaccidental trauma in a child presenting in shock with no other preceding symptoms Trauma or suspected trauma patients should undergo a full trauma evaluation including the primary and secondary surveys as detailed in Chapter A General Approach to the Ill or Injured Child Careful evaluation for evidence of bleeding including assessment of open fontanelles, all orifices, and thorough abdominal examination POCUS findings: The focused assessment with sonography in trauma (FAST) examination may identify areas of internal bleeding (e.g., abdominal, pericardial) Hypovolemic Shock Determine if volume loss may be due to decreased intake or increased output (vomiting, diarrhea) On physical examination, one should assess the following: Mental status/level of activity Sunken fontanelle and/or eyes Skin turgor Capillary refill Urine output POCUS findings: Ratio of inferior vena cava to aorta (IVC/Ao) 50% respiratory variation (nonintubated patients) and >20% respiratory variation in the IVC diameter on longitudinal view Repeat POCUS examinations during volume resuscitation can be used to evaluate for changes to the above parameters to