Differential Diagnosis

A. Hypovolemia. Gastroenteritis is the most common cause of hypotension in children. Assess patient's intake and output (I&Os) since admission, but keep in mind that much fluid may still be present in the gut, and that third spacing of fluid may be occurring.

B. Incomplete Resuscitation. Fluid losses may continue. Despite what may appear to be adequate initial resuscitation, continue to provide fluid resuscitation if appropriate.

C. Cardiac Dysfunction. Although uncommon in pediatric patients, myocarditis may present with hypotension and sinus tachycardia. Likewise, pericarditis with pericardial effusion and cardiac tamponade may present in a similar fashion. Finally, consider other things that may impair cardiac output: tension pneumothorax, high positive end-expiratory pressure if mechanically ventilated (may impair venous return), and myocardial ischemia.

D. Sepsis. Many types of infection in children can be associated with diarrhea and subsequent hypovolemia. If child does not seem to be responding to initial efforts at resuscitation, a more serious infection must be considered. Bacterial toxins and subsequent release of circulating cytokines can decrease cardiac function and cause vasodilation, resulting in hypotension (frequently associated with lactic acidosis).

E. Neurogenic Shock. Disturbance of vasomotor tone from injury such as trauma to the spinal cord; typically results in hypotension and tachycardia.

F. Vasogenic Shock. Inappropriate loss of vasomotor tone can be seen with sepsis, anaphylaxis, adrenal insufficiency, and medications.

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