Hypovolaemic and haemorrhagic shock — formative SAQs

1. First 60 seconds

"This child is critically unwell with signs of shock: altered appearance, increased work of breathing and poor circulation to skin. I call the senior paediatric and resuscitation teams now, name a leader, allocate roles, and bring age- and weight-appropriate equipment and monitoring. I begin the hands-on ABCDE primary survey immediately and treat each threat as I find it. Stabilisation comes before diagnosis." The principle is recognise and call for help, then treat life threats as they are found. I also check bedside glucose because the child has poor intake and is unwell. ^{[1] [2]}

2. Blood pressure does not exclude shock

Children compensate for volume loss through tachycardia and vasoconstriction, so blood pressure is maintained until roughly 30 per cent of blood volume is lost. This child already shows poor perfusion: a heart rate of 165, weak central pulses, a five-second capillary refill, cool mottled limbs and altered consciousness. That is decompensated shock in evolution despite a low-normal blood pressure. Waiting for hypotension to diagnose shock is a classic and dangerous error; shock is a whole-circulation diagnosis, never a single blood-pressure number. ^[2]

3. Fluid resuscitation

Because there is no bleeding, this is non-haemorrhagic hypovolaemic shock, so I resuscitate with a balanced crystalloid such as Hartmann or Plasma-Lyte rather than large volumes of 0.9 per cent saline, which worsens hyperchloraemic acidosis. I give an aliquot of 10 to 20 mL per kilogram over five to twenty minutes. Before each aliquot I state the response I expect (warmer skin, shorter capillary refill, stronger pulses, improved interaction, more urine), and after each I reassess and stop for fluid overload or no benefit. The first-hour total is a ceiling, not a target. The Surviving Sepsis Campaign 2026 children's guideline supports up-front boluses with careful reassessment and attention to fluid balance. ^[4]

4. Change if this were haemorrhage

If the child had major haemorrhage, the first fluid would change from crystalloid to blood products. I would first control the bleeding with direct pressure, a tourniquet or a pelvic binder as appropriate, then activate the paediatric massive transfusion protocol to deliver balanced components (red cells, plasma and platelets in a ratio near one to one to one). I would give tranexamic acid if the injury was within three hours. I would keep crystalloid to the minimum needed to sustain perfusion while blood arrives, because large crystalloid volumes dilute clotting factors and worsen the lethal triad of hypothermia, acidosis and coagulopathy. The first decision in any shock is bleeding or not bleeding, because that decides the first fluid. ^{[5] [9]}