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Assessing dehydration and shock

Table 4.5 Classification of dehydration severity by the American Subcommittee on Acute Gastroenteritis 5

Variable Mild, 3–5% Moderate, 6–9% Severe, ≥10%
Blood pressure Normal Normal Normal to reduced
Quality of pulses Normal Normal or slightly decreased Moderately decreased
Heart rate Normal Increased Increased
Skin turgor Normal Decreased Decreased
Fontanelle Normal Sunken Sunken
Mucous membrane Slightly dry Dry Dry
Eyes Normal Sunken orbits Deeply sunken orbits
Extremities Warm, normal capillary Delayed capillary refill Cool, mottled
refill
Mental status Normal Normal to listless Normal to lethargic or comatose
Urine output Slightly decreased <1 ml/kg per hour << 1 ml/kg per hour
Thirst Slightly increased Moderately increased Very thirsty or too lethargic to indicate

signs of dehydration in addition to the specific clinical manifestations of shock. However, this
might not always be the case. For example, a small infant with gastroenteritis might experience
sudden severe fluid loss at the onset of gastroenteritis sufficient to cause hypovolaemic shock
before any signs of dehydration (for example, dry mucous membranes or reduced skin turgor)
were present. Hence it was appropriate to distinguish the symptoms and signs of shock from
those of dehydration. Inevitably, there was some overlap, in that both dehydration and shock
might be associated with a change in conscious state. In dehydration, lethargy or irritability might
commonly occur, while in shock there might be a more profound depression of consciousness.
Likewise, dehydration would often cause an increased heart rate but in shock this might be much
more pronounced. The diagnosis of shock would be based on the clinician’s global assessment,
taking account of each of the relevant symptoms and signs. With severe shock the manifestations
would be unequivocal. In lesser degrees of shock, for example as the symptoms and signs first
appeared, there might be some difficulty in distinguishing it from severe dehydration. The GDG
concluded that when there was uncertainty the safe approach would be to treat as though shock
was present (Section 5.4).
The GDG identified several ‘red flag’ signs in dehydration whose presence should alert the
clinician to a risk of progression to shock (see Table 4.6). These were altered responsiveness (for
example, irritable, lethargic), sunken eyes, tachycardia, tachypnoea, and reduced skin turgor.
Children with such red flag signs require especially careful consideration and close monitoring.
The GDG considered that monitoring to follow the ‘illness trajectory’ was critically important
particularly in these ill children. Thus tachycardia (a red flag sign) would be of even greater
concern if it worsened over time, pointing to a serious risk of clinical deterioration and shock.
The GDG recognised that this recommended clinical assessment scheme was novel and would
be unfamiliar to clinicians. However, it had the great advantage of simplicity, would be easy
to implement, and would provide the clinical information necessary for appropriate fluid
management. As discussed later in Chapter 5, those with dehydration will usually be treated with
oral fluid rehydration, those with red flag symptoms and/or evidence of deterioration will require
careful management, probably in a hospital setting, while those with suspected or definite shock
will require emergency IVT in hospital. In the community setting, it will be necessary for the
healthcare professional to decide whether monitoring the response to rehydration therapy can be
carried out safely in the home setting and if so under what level of supervision (general practitioner,
community children’s nurse, etc.). Where there are concerns about a parent’s ability to monitor
their child’s condition and to provide appropriate care, referral to hospital might be required.
The GDG considered that recognition of the symptoms and signs of dehydration and shock needs
considerable expertise. Clinicians therefore require training and experience in order to ensure
competence in assessing children with gastroenteritis. This should be at an appropriate level to
allow the individual to work safely and effectively in their specific clinical role.

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