Give intravenous Ringer’s lactate or normal saline 20 ml/kg as fast as possible. Continue to give fluid at this fast rate until the signs of shock have disappeared. An easily felt radial pulse and normal capillary filling time are very reassuring signs of a good response to management. Once shock has been corrected, Ringer’s lactate, half normal saline or half Darrows/dextrose solution is then given at the standard rate for severe dehydration (i.e. 30 ml/kg per hour).
20 ml/kg of intravenous fluid is given as fast as possible if shock is present.
If it is not possible to start an intravenous line, the intraosseous route can be used in young children if the health worker is trained in this technique. A nasogastric drip can be used if neither intravenous or intraosseous routes are available. Haemacel, fresh frozen plasma or stabilized human serum (SHS) can also be used to treat shock. Using the intraosseous route in children under six years of age can be a life-saving procedure.
In an emergency with ongoing shock, where several attempts to place an intravenous line have failed, use the intraosseous route. The most suitable site is 2 cm below the tibial tuberosity on the flat surface of the tibia (shin bone). A wide-bore needle (15–18 gauge) can be used if a needle with stylet is not available. In children under 18 months, an 18 × 1.5 or 20 × 1.5 lumbar puncture needle is suitable. Hold the needle perpendicular to the skin and with a twisting movement push it into the flat part of the tibia until a ‘give’ is felt; the needle is now in the bone marrow. Do not advance it any further. In a shocked patient, fluid must be introduced under pressure (use a 20 ml syringe as a ‘push-in’ or a sphygmomanometer cuff wrapped around a collapsible IV plastic fluid container). The dosage and volume of drugs and fluid are the same as for direct IV infusion.