Type

Comment

All of these conditions are characterized by an

intravascular hypovolemia caused by:
Distributive

Vasodilation
(Includes neurogenic and anaphylactic;

Increased capillary permeability

some authors also include septic shock

Third-space fluid losses

in this category)
Most common type of shock worldwide.
Results from inadequate fluid intake to
compensate for fluid output (e.g., vomiting,
diarrhea, hemorrhagic fluid loss).
Signs and symptoms include:

Hypovolemic

Mental status changes

Tachypnea
Tachycardia
Hypotension
Cool extremities
Oliguria

Rare in children, but may be associated with the

following conditions:

Severe congenital heart disease

Dysrhythmias
Cardiomyopathy
Tamponade

Signs and symptoms include:

Cardiogenic

Cool extremities
Delayed capillary refill (> 2 seconds)
Hypotension
Tachypnea
Increasing obtundation
Decreased urine output

Results when infectious organisms release toxins

that affect fluid distribution and cardiac output.
Can result from bacterial, viral, orin
immunocompromised patientsfungal
infections.
Patients in septic shock typically require
repeated boluses of fluid. They may also need
medications (epinephrine, norepinephrine or
dopamine) to enhance cardiac contractility and
to vasoconstrict the vessels.

Septic

It is important to realize that patients in septic

shock may present initially as compensated or
"warm" shock, with the following findings:

Warm extremities

Bounding pulses

Tachycardia

Tachypnea

Adequate urination

Mild metabolic acidosis

Hypovolemic (hemorrhage, diarrhea/dehydration) and septic shock are the most common
causes of shock in children.

Causes of alt mental status:

Alcohol, ingested toxins

Epilepsy, encephalitis, endocrine, electrolytes

Infection, insulin

Overdose, opiates, oxygen deprived

Uremia (renal failure)

Trauma, temperature

Insulin, infection

Psychosis

Stroke, shock, space occupying lesions

Drug Class
(examples)

Classic Clinical Features (Toxidrome)

Miosis and blurred vision

Increased gastric motility (nausea, vomiting,
diarrhea)
Excessive tearing, salivation, sweating and urination
Bronchorrhea and bronchospasm
Muscle twitching and weakness
Bradycardia
Seizures and coma

Cholinergic
(organophosphates)

Mnemonic: "SLUDGE" (salivation, lacrimation, urination,

defecation, GI motility, emesis)

Anticholinergic
(diphenhydramine, tricyclic
antidepressants)

Mydriasis (dilated pupils) "blind as a bat"

Dry skin "dry as a bone"
Red skin (flushed) "red as a beet"
Fever "hot as Hades"
Delirium and seizures "mad as a hatter"
Tachycardia
Urinary retention
Ileus

Blurred vision (miosis or mydriasis)

Hypotension
Apnea and bradycardia
Hypothermia

Sedative-hypnotic
(benzodiazepines,
barbiturates)

Opioids
(codeine, morphine, heroin)
Sympathomimetics
(cocaine, amphetamines,
pseudoephedrine)

Medication
Cholinergic

Mydriasis
Fever and diaphoresis
Tachycardia
Agitation and seizures

Skin

HR
decreased

Diaphoret Constrict
ic
ed

HR
elevated
Hyperther
mia
Dry

Opioid

Sympathomim
etic

Defined
Organi
c

Miosis (constricted pupils)

Respiratory depression
Bradycardia and hypotension
Hypothermia
Depressed mental status (sedation, confusion,
coma)

Vitals

Anticholinergi
c

Sedativehypnotic

Sedation, confusion, delirium, coma

Pupils

Hypoactive

Altered sensory
exam

Constrict
ed

HR
elevated
RR
elevated
BP
elevated
Hyperther Diaphoret
mia
ic
Dilated

Abdominal
exam
Hyperactive

Dilated

HR
depressed
BP
depressed
RR
depressed
HR
depressed
BP
depressed
RR
depressed
Hypother
mia

Other neuro
findings

Hypoactive

Hypoactive

Hyperreflexia

Hyperactive

Common Causes

Organic FTT is diagnosed when growth failure is

caused by an acute or chronic disorder that results in

Congenital heart
defects

inadequate nutrient intake, malabsorption of

nutrients, or increased energy requirements.

Infants and children with organic FTT typically

have history and physical findings associated with the
underlying disease (e.g., cough, heart murmur,
vomiting or diarrhea, recurrent infections, persistent
rashes) in addition to poor weight gain. Isolated poor
weight gain is unusual.
Non-organic FTT is diagnosed when poor growth
does not result from an underlying disease or
disorder.

Nonorgani
c

Cystic fibrosis
Developmental
delay with poor suck
and swallow
Renal tubular
acidosis, and
Milk protein
allergy
HIV
Vomiting caused
by severe
gastroesophageal
reflux or bowel
obstruction.

Nearly 90% of FTT cases are non-organic.

Inadequate caloric intake

may result from:

It occasionally reflects neglect of the infant (e.g.,

lack of food).

Less commonly, there is a psychological basis of

non-organic FTT in which stimulation is lacking

because the caregiver is depressed or has another

mental illness, has poor parenting skills, or is

responding to real or perceived external stresses.

Poverty
Poor
understanding of
feeding techniques
Improperly
prepared formula, or
Inadequate supply
of breast milk.

Milestones in Speech Development

Age
Milestone(s)*
Before 7 days of

Can distinguish mother's voice from another woman's voice.

age
Before 2 weeks

of age

Can distinguish father's voice from another man's voice

At 6-8 months

Has added a few consonant sounds to the vowel sounds.

May say "mama" or "dada" but does not attach them to individuals.

At 1 year

Will attach "mama" or "dada" to the correct person.

Responds to one-step commands such as "Give it to me."

At 15 months

At 18 months
At 2 years

Continues to string vowel and consonant sounds together (gibberish), but

may imbed real words.
May say as many as 10 different words.
Can say nouns (ball, cup), names of special people, and a few action words
or phrases.
Can add gestures to her speech, and may be able to follow a two-step
command.
Can combine words, forming simple sentences like "Daddy go."

Capillary hydraulic
pressure

Influenced by systemic and venous blood pressure, local blood flow, and preand postcapillary resistances.

Interstitial fluid
pressure

Usually negative; moves fluid out of the capillary.

When positive, interstitial fluid pressure results in movement of fluid into the
capillary.

Plasma colloid
osmotic pressure

Due to proteins dissolved in plasma and interstitial fluid that do not diffuse
through the capillary wall.
Normally, the intracapillary colloid osmotic pressure causes transfer of fluid
into the capillary.

Interstitial fluid
osmotic pressure

Due to the small amount of plasma proteins that leak through larger capillary
pores and cause an osmotic shift of fluid out of capillaries.