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Recognition and management of shock in the pediatric population follow the same general principles as in adults, with a few notable exceptions [46]. Children in shock more commonly present with a low cardiac output and a relatively high systemic vascular resistance (SVR). This has been described as “cold shock,” as opposed to the low‐SVR state or “warm shock” frequently seen in adults. Children presenting in distributive shock usually require more aggressive fluid resuscitation with volumes of 60 cc/kg or more [47]. If children fail to respond to the initial fluid resuscitation, epinephrine is preferred as the first‐line vasopressor to counter the relatively low cardiac output seen in pediatric shock. Additional support for patients with low SVR and wide pulse pressure may be provided with norepinephrine or vasopressin. Dobutamine may provide inotropic and chronotropic support in patients with very low cardiac output and improve delivery of oxygen to tissues.

Following initial treatment with fluids and vasoactive agents, pediatric patients may also benefit from adjunctive therapies for shock [46]. Early airway management should be considered, as children may use up to 40% of their cardiac output to support the work of breathing. Ketamine is the preferred induction agent, as it preserves cardiac output and will not result in the hypotension or adrenal suppression potentially seen with other induction agents. Hydrocortisone should be administered to children with adrenal insufficiency. Transport to an appropriate facility with pediatric critical care should be an important consideration.