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Clinical Signs of Circulatory Impairment/Shock in Children: A Prospective Observational Study
Jhuma Sankar1, Javed Ismail2, Vineet Kr Kamal3
1Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), New Delhi, India. jhumasankar@aiims.edu.
Insights
Feeble pulses are the best clinical sign for identifying shock in children, offering high accuracy. Tachycardia and prolonged capillary refill time also indicate shock, guiding urgent interventions.
Area of Science:
- Pediatric Emergency Medicine
- Critical Care Pediatrics
- Clinical Diagnostics
Background:
- Early identification of shock in children is crucial for timely intervention and improved outcomes.
- Existing clinical signs for shock diagnosis in pediatric emergencies have variable accuracy.
- The predictive value of clinical signs may differ in vulnerable pediatric populations, such as those with malnutrition or severe anemia.
Purpose of the Study:
- To assess the diagnostic accuracy and predictive capability of various clinical indicators for shock in children.
- To compare the effectiveness of different clinical signs in identifying pediatric patients needing immediate medical intervention.
- To investigate the performance of these signs in children with co-existing malnutrition or severe anemia.
Main Methods:
- A prospective study enrolled 2,579 children (2 months to 17 years) presenting with acute illness to a pediatric emergency department.
- Children were categorized into shock (requiring fluid/vasoactive agents within 1 hour) and non-shock groups.
- Diagnostic accuracy of clinical signs was evaluated, with analysis stratified by malnutrition and severe anemia status. Classification and Regression Tree (CART) analysis was used to develop a predictive model.
Main Results:
- Feeble pulses exhibited the highest sensitivity and specificity (>85%) for shock detection, with a diagnostic odds ratio of 38.8.
- Tachycardia and capillary refill time (CRT) >2 seconds showed sensitivity and specificity exceeding 70%.
- Hypotension and coma were the most significant shock predictors in children with malnutrition and severe anemia. A CART model identified three shock scenarios involving combinations of feeble pulses, tachypnea, hypotension, and cool peripheries.
Conclusions:
- Feeble pulses are the most reliable clinical predictor of shock in acutely ill children, followed by tachycardia and prolonged CRT.
- A CART-derived bedside model, incorporating multiple clinical signs, shows promise for identifying children with shock requiring urgent treatment.
- Further validation of the CART model is recommended for its potential bedside application in pediatric emergency settings.
Objectives:
To evaluate the diagnostic accuracy and predictive ability of various clinical signs of shock for identifying children requiring immediate intervention.
Methods:
The authors conducted this prospective study (2019-2023) in children aged 2 mo to ≤ 17 y presenting to the pediatric emergency with an acute illness. Children with shock, defined by the presence of one/more clinical signs and, requirement for fluid boluses/vasoactive agents within the first hour were compared with children without shock. The primary outcome was to evaluate the diagnostic accuracy of the clinical signs; further stratified by malnutrition and severe anemia.
Results:
Two thousand five hundred seventy-nine (2,579) children were enrolled, 288 in the shock group and 2291 in the non-shock group. Feeble pulses demonstrated the best sensitivity and specificity (> 85%) with a diagnostic odds ratio of 38.8 (95% CI: 27.2, 55). Tachycardia and capillary refill time (CRT) > 2 s demonstrated sensitivity and specificity of > 70% each. In children with malnutrition and severe anemia, hypotension and coma were the strongest predictors of shock. Using Classification and Regression Tree (CART) analysis, the authors developed a model and validated it in internal and external datasets. Three primary scenarios emerged in the CART analysis, comprising of a combination of feeble pulses, tachypnea, hypotension and/or cool peripheries.
Conclusions:
In children presenting with acute illness, presence of feeble pulses was the best predictor of shock followed by tachycardia and prolonged CRT. The CART model, which showed three possible scenarios, needs further validation and may be used as a bedside approach to identify patients with shock requiring interventions.
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