Resuscitate the circulation, not the number — paediatric septic shock

Station status

This is one MedVellum formative structured clinical encounter. The scoring, prompts and performance descriptions are educational feedback tools. They are not an official college station, timing, mark allocation, pass score or reproduced examination format. The encounter assesses first-impression recognition of shock, leadership of the first-hour bundle, the reassessed-fluid philosophy, the choice of adrenaline for cold shock, recognition of fluid accumulation injury, communication, escalation and a structured handover. [1] [5]

Candidate instructions

You are the paediatric registrar called to the acute assessment room. Assess the child from the doorway and say aloud what you see. Recognise shock from the whole circulation, not the blood pressure. Lead the first-hour bundle: secure airway and oxygen, establish access, give reassessed fluid aliquots, give antibiotics within the hour, and start a vasoactive agent if shock is fluid refractory. Speak directly to the child and parent. Reassess after every action. Call senior, critical-care or retrieval support early. Finish with a structured handover and disposition plan. Say what you would assess or do; do not perform painful or distressing manoeuvres on the actor. [1]

Room setup and observable starting state

The encounter. Mia is four and is supported on the assessment trolley by a parent. The parent says simply, "She's gone really cold." Mia is drowsy, opens her eyes briefly to voice, has marked recession, and looks pale with mottled knees and cold limbs. These are abnormalities in appearance, work of breathing and circulation to skin. The candidate should describe these signs objectively, declare concern, recognise decompensated septic shock in evolution despite a non-hypotensive blood pressure, and begin the first-hour bundle immediately. [5]

Simulation safety. Mia remains on the trolley and is never forcibly positioned. Cards or the assessor supply recession, breathing sounds, monitor readings and examination findings. The parent does not obstruct urgent care. [1]

Actor cues

Parent actor

• Begin with "She's gone really cold." If asked what has changed, answer: "Mia is usually full of energy. For two days she's had a fever and hardly drunk anything, and today she's cold and floppy and barely wakes up." [1]

Child actor

• Respond briefly to voice early in the encounter; become drowsier and harder to rouse as the scenario progresses, following the assessor's cue card. [1]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward recognition of shock from the whole circulation and the reassessed-fluid philosophy; penalise waiting for hypotension or treating the ceiling as a target. [1]

A and B — Airway and breathing

Airway is patent but the voice is weak. Respiratory rate 42, marked recession, reduced bilateral air entry, oxygen saturation 91% on air with a reliable waveform. Expected strong behaviour: give high-flow oxygen because the child is in failure; state a target of 94 to 98% for this previously well child; judge effectiveness by air entry and interaction; prepare bag and mask. [1]

C — Circulation

Heart rate 165, weak central pulses, capillary refill 4 seconds, blood pressure low-normal, cool mottled limbs, reduced urine output. Bedside glucose 2.2 mmol per litre. Expected strong behaviour: diagnose shock from the whole picture despite a non-hypotensive blood pressure; gain intravenous or intraosseous access; send gas, lactate, glucose, culture and bloods; give crystalloid aliquots of 10 to 20 mL per kilogram stating the expected response and reassessing after each; correct the dangerously low glucose immediately through the local pathway; give broad-spectrum antibiotics within the first hour. [1] [5]

Escalation event — fluid-refractory cold shock

After two reassessed boluses totalling 40 mL per kilogram, Mia remains cold and mottled with weak thready pulses and a narrow pulse pressure. Expected strong behaviour: recognise fluid-refractory septic shock; identify the cold phenotype; start an adrenaline infusion at 0.05 to 0.1 microgram per kilogram per minute titrated to perfusion; arrange central access and intensive care; call retrieval in parallel. [1] [6]

Escalation event — fluid accumulation injury

On the adrenaline infusion, Mia develops bilateral crackles, hepatomegaly and a rising oxygen requirement while perfusion remains poor despite an adequate dose. Expected strong behaviour: recognise fluid accumulation injury and stop driving fluid; recognise catecholamine-resistant shock; reconsider reversible causes (tamponade, pneumothorax, undrained source, hypoadrenalism); add stress-dose hydrocortisone; arrange echocardiography and ventilatory support. [1] [9]

Weight and retrieval

The candidate must obtain a working weight for drug and device sizing, using a measured weight or the local cognitive aid, and must call retrieval before local support is exceeded. Expected strong behaviour: state the working weight and its source; agree destination, treatment, escort, expected deterioration and the plan if transfer is delayed; run a structured handover. [1]

Marking domains

Debrief prompts

• What made you confident this was shock before the blood pressure fell?
• Why did you stop at two boluses and start adrenaline rather than continuing fluid?
• How did you decide between adrenaline and noradrenaline for this child?
• What sign told you fluid was now causing harm, and what did you change?
• What contingency did you agree with retrieval for deterioration during transport? [1]