## Pediatric Shock Fluid Resuscitation Protocol **Key Point:** The first-line fluid bolus in pediatric shock is 20 mL/kg of isotonic crystalloid — either 0.9% Normal Saline (NS) or Lactated Ringer's (LR) — administered over 15–30 minutes. ### Rationale - Both NS and LR are isotonic solutions that expand the intravascular space without causing cellular edema. - LR is preferred in some settings (e.g., burn resuscitation, sepsis) because it contains potassium and calcium and has a lower chloride load, reducing hyperchloremic acidosis. - NS is equally acceptable and more widely available. ### Repeat Boluses - If shock persists after the first bolus, a second 20 mL/kg bolus is given. - A third bolus may be considered, but if shock does not respond after 60 mL/kg of crystalloid, inotropic support and vasopressor therapy should be initiated. **High-Yield:** Remember the **"20-20-20" rule** in pediatric shock: first bolus 20 mL/kg, repeat if needed, and reassess after 60 mL/kg total. ### Why NOT the Other Solutions - **0.45% Hypotonic Saline:** Causes fluid shift into intracellular space; inappropriate for shock resuscitation. - **5% Dextrose in Water:** Hypotonic and provides no osmotic support; glucose is metabolized, leaving free water that worsens cerebral edema. - **3% Hypertonic Saline:** Reserved for severe hyponatremia or raised intracranial pressure; not first-line for shock resuscitation in children. **Clinical Pearl:** In hemorrhagic shock, some centers use a balanced approach of crystalloid + blood products (1:1:1 ratio of PRBC:FFP:platelets in damage control resuscitation), but the initial bolus is still isotonic crystalloid. [cite:Park 26e Ch 5] 
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.