Clinical scenario: Shock | Management
A 7-year-old boy is brought to the emergency department with a 24-hour history of fever, vomiting, and progressive lethargy. On examination, he is confused, with a temperature of 39.5°C, heart rate of 170/min, respiratory rate of 44/min, and blood pressure of 90/55 mmHg. His extremities are warm, peripheral pulses are bounding, capillary refill time is 1 second, and urine output is less than 0.5 mL/kg/hour. Serum lactate is 5.8 mmol/L.
Which of the following best describes his hemodynamic state?
A. Cardiogenic shock
B. Compensated septic (warm) shock
C. Decompensated hypovolemic shock
D. Obstructive shock
E. Septic (cold) shock
Correct answer & Explanation:
Correct Answer: B. Compensated septic (warm) shock
Explanation: Septic shock
This child has compensated septic (warm) shock.
The diagnosis is supported by:
- Fever suggesting sepsis
- Tachycardia with maintained systolic blood pressure
- Warm extremities
- Bounding peripheral pulses
- Brisk capillary refill (1 second)
- Elevated serum lactate indicating tissue hypoperfusion
- Reduced urine output, an early marker of organ hypoperfusion
These findings reflect the hyperdynamic phase of septic shock, in which systemic vascular resistance is reduced while cardiac output is increased. Although blood pressure is still preserved, tissue perfusion is already impaired.
Why the other options are incorrect
A. Cardiogenic shock
Usually presents with cold extremities, weak pulses, prolonged capillary refill, hepatomegaly, and pulmonary edema, reflecting reduced cardiac output.
B. Compensated septic (warm) shock
Correct. Warm extremities, bounding pulses, brisk capillary refill, elevated lactate, and preserved blood pressure are characteristic of the early hyperdynamic phase of septic shock.
C. Decompensated hypovolemic shock
Typically presents with prolonged capillary refill, weak pulses, cool extremities, hypotension, and narrow pulse pressure, rather than bounding pulses and warm extremities.
D. Obstructive shock
Occurs with conditions such as cardiac tamponade, tension pneumothorax, or massive pulmonary embolism, which are not suggested by this clinical presentation.
E. Septic (cold) shock
Characterized by cold extremities, prolonged capillary refill, weak peripheral pulses, and increased systemic vascular resistance, unlike the warm, vasodilated state seen here.
Learning Point
Children with compensated septic shock may have normal blood pressure, because hypotension is a late and preterminal sign.
Features of warm septic shock include:
- Warm extremities
- Bounding pulses
- Flash (brisk) capillary refill
- Wide pulse pressure
- Elevated lactate
- Reduced urine output
Recognition at this stage is crucial because early antibiotics and prompt fluid resuscitation improve outcomes.
