Correction of electrolyte and metabolic disturbances

00000000Hyponatraemia and metabolic acidosis occur commonnly in severe cases. Electrolyte levels and blood gases should be determined periodically in severely ill patients and in those with refractory shock. Serum calcium may be low in some cases, perticularly in cases with massive plasma and/ or blood transfusion. Occasionally hypoglycaemia may develop.

Sedatives

00000000Sedative therapy may be needed in some cases, as agitated child needs restraining. Hepatotoxic drugs should be avoided. Chloral hydrate, orally or rectally, is recommended in a dose of 12.5 - 50 mg/kg (but not over one g), to be used as a single hypnotic dose.

Oxygen therapy

00000000 Oxygen therapy should be given to all patients with shock. However, the oxygen mask or tent increases the apprehension of the patient.

Blood transfusion

00000000 Blood transfusion is indicated in cases with significant clinical bleeding, most often with haematemesis and melaena. Fresh whole blood (FWB) is preferable and blood should be given only in volume such that the red blood cell mass becomes normal. Fresh frozen plasma, concentrated platelets and cryoprecipitate are indicated in some cases, when consumptive coagulopathy causes significant bleeding.

00000000 Persisting shock with declining haematocrit level (e.g. from 50 per cent to 40 per cent) indicates significant clinical bleeding which requires prompt treatment.

00000000 It may be difficult to recognize and estimate the degree of internal blood loss in the presence of haemoconcentration. It is thus recommended to give FWB in small volumes at a time. Insertion of an intragastric tube to determine concealed bleeding or to stop bleeding (by cold lavage) is hazardous and is not recommended. DIC is usually present in severe shock and it may play an important part in the development of massive bleeding and lethal shock. The coagulogram [prothrombin times (PT), PTT and thrombin times (TT)] should be studied in all shock cases to document the onset and severity of DIC which determine the prognosis. Generally anticoagulant therapy is not indicated for DIC. However, in patients with prolonged shock where metabolic acidosis has developed, and in whom shock is refractory to conventional regimens, the use of heparin may be justifiable in order to break a vicious cycle of shock and DIC before the stage of irreversibility is reached. In all instances, extreme caution should be exercised in using heparin.

00000000 Blood grouping and matching of every patient with shock should be carried out as a routine precaution.