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[ Home ](https://mdster.com) 2. [ Blog ](https://mdster.com/blog) 3. [ Case Discussion ](https://mdster.com/blog?category=case-discussion) 4. Bronchiolitis to Pediatric Shock: PEWS, I-PASS, Resuscitation [ Case Discussion ](https://mdster.com/blog?category=case-discussion) Bronchiolitis to Pediatric Shock: PEWS, I-PASS, Resuscitation =============================================================== A case discussion on missed deterioration, cold shock physiology, lactate, handoff failure, and safer overnight escalation. [ MDster Editorial Team ](https://mdster.com/about) · Jun 16, 2026 · 6 min read · 40 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) | [Corrections Policy](https://mdster.com/corrections) [ Patient Safety ](https://mdster.com/blog?tag=patient-safety) [ Pediatrics ](https://mdster.com/blog?tag=pediatrics) [ Bronchiolitis ](https://mdster.com/blog?tag=bronchiolitis) [ Resuscitation ](https://mdster.com/blog?tag=resuscitation) [ Pediatric Shock ](https://mdster.com/blog?tag=pediatric-shock) [ PEWS ](https://mdster.com/blog?tag=pews) ![Bronchiolitis to Pediatric Shock: PEWS, I-PASS, Resuscitation](https://mdster.com/storage/blog/images/bronchiolitis-to-pediatric-shock-pews-i-pass-resuscitation.jpg) Share this article Share this post On this page 1. [ The Case Signal: Bronchiolitis Became Shock ](#the-case-signal-bronchiolitis-became-shock) 2. [ Differential Diagnosis at the Bedside ](#differential-diagnosis-at-the-bedside) 3. [ Lactate and the Physiology of Collapse ](#lactate-and-the-physiology-of-collapse) 4. [ First Three Hemodynamic Moves ](#first-three-hemodynamic-moves) 5. [ 1. Fix oxygen delivery now ](#1-fix-oxygen-delivery-now) 6. [ 2. Get access without drama ](#2-get-access-without-drama) 7. [ 3. Give fluid in aliquots and reassess ](#3-give-fluid-in-aliquots-and-reassess) 8. [ The Preventable Failure: PEWS, Bias, and Handoff ](#the-preventable-failure-pews-bias-and-handoff) 9. [ What PEWS should have caught ](#what-pews-should-have-caught) 10. [ The cognitive trap ](#the-cognitive-trap) 11. [ The handoff miss ](#the-handoff-miss) 12. [ Debrief and Just Culture ](#debrief-and-just-culture) 13. [ Key Points for Board Exams ](#key-points-for-board-exams) 14. [ Clinical Application ](#clinical-application) 15. [ Frequently Asked Questions ](#blog-faqs) 16. [ References ](#references-heading) On this page 1. [ The Case Signal: Bronchiolitis Became Shock ](#the-case-signal-bronchiolitis-became-shock) 2. [ Differential Diagnosis at the Bedside ](#differential-diagnosis-at-the-bedside) 3. [ Lactate and the Physiology of Collapse ](#lactate-and-the-physiology-of-collapse) 4. [ First Three Hemodynamic Moves ](#first-three-hemodynamic-moves) 5. [ 1. Fix oxygen delivery now ](#1-fix-oxygen-delivery-now) 6. [ 2. Get access without drama ](#2-get-access-without-drama) 7. [ 3. Give fluid in aliquots and reassess ](#3-give-fluid-in-aliquots-and-reassess) 8. [ The Preventable Failure: PEWS, Bias, and Handoff ](#the-preventable-failure-pews-bias-and-handoff) 9. [ What PEWS should have caught ](#what-pews-should-have-caught) 10. [ The cognitive trap ](#the-cognitive-trap) 11. [ The handoff miss ](#the-handoff-miss) 12. [ Debrief and Just Culture ](#debrief-and-just-culture) 13. [ Key Points for Board Exams ](#key-points-for-board-exams) 14. [ Clinical Application ](#clinical-application) 15. [ Frequently Asked Questions ](#blog-faqs) 16. [ References ](#references-heading) At 05:00, a 10-month-old with bronchiolitis is obtunded, mottled, hypotensive, and hypoxemic. The miss was not the virus; it was the trajectory. Sustained HR 190, RR 65, rising oxygen need, and no bedside reassessment should never survive the night as fever or fussiness. The Case Signal: Bronchiolitis Became Shock ------------------------------------------- This infant began with moderate bronchiolitis: alert, RR 48, mild retractions, SpO2 94% in room air. AAP bronchiolitis guidance supports clinical diagnosis and avoidance of routine labs or radiography in typical cases, but that advice does not apply once perfusion, mental status, or hemodynamics change. [\[1\]](#cite-1 "Reference [1]") By 02:00, the infant had sustained tachycardia and tachypnea without meaningful fever. By 05:00, BP 60/35, weak central pulses, cool extremities, capillary refill 4 seconds, SpO2 85% on oxygen, and lactate 4.5 mmol/L indicated decompensated shock. ### Differential Diagnosis at the Bedside Treat first, classify in parallel. In this vignette, the working differential includes: - Bronchiolitis with impending respiratory failure and hypoxemic shock - Dehydration or hypovolemia from poor intake and increased losses - Suspected septic shock from bacterial coinfection, pneumonia, UTI, or viral sepsis - Myocarditis or cardiomyopathy presenting as bronchiolitis mimic - SVT or another tachyarrhythmia, especially if the rate is fixed and perfusion worsens Cool extremities, delayed capillary refill, weak pulses, altered mental status, and hypotension best fit **decompensated cold shock**. If infection is plausible, current terminology would frame this as suspected septic shock with a cold, low-output phenotype. Lactate and the Physiology of Collapse -------------------------------------- The lactate is not a diagnosis; it is a perfusion alarm. In this infant, DO2 has fallen below cellular demand, so pyruvate is shunted toward lactate during anaerobic glycolysis. Catecholamine-driven glycolysis can contribute, but hypotension plus weak pulses makes hypoperfusion the dominant concern. The 2026 Surviving Sepsis Campaign pediatric guideline recommends lactate measurement during initial evaluation of probable sepsis or suspected septic shock, while emphasizing serial clinical reassessment rather than treating a number in isolation. [\[2\]](#cite-2 "Reference [2]") > **Clinical Pearl:** In infants, hypotension is late. A sustained unexplained HR near 190 with worsening RR is already a shock conversation, not a documentation detail. First Three Hemodynamic Moves ----------------------------- ### 1. Fix oxygen delivery now Call for PICU, respiratory therapy, pharmacy, and experienced airway help. Provide high-FiO2 support; use HFNC if breathing is spontaneous and effective, but move to BVM ventilation if mental status, fatigue, or gas exchange is failing. Intubation may be necessary, but induction in shock requires senior planning because apnea, sedatives, and positive pressure can unmask cardiovascular collapse. ### 2. Get access without drama Attempt IV rapidly, but do not let multiple attempts delay resuscitation. IO access is appropriate when IV access is not promptly obtained. Send glucose, blood gas, lactate, electrolytes, CBC, blood culture, and targeted studies, but resuscitation owns the clock. ### 3. Give fluid in aliquots and reassess For this 8-kg infant, give 10–20 mL/kg isotonic crystalloid, or 80–160 mL per aliquot, with reassessment after each bolus. Examine liver edge, lung fields, pulses, capillary refill, mental status, BP, urine output, and work of breathing. AHA/AAP PALS supports 10- or 20-mL/kg aliquots with frequent reassessment in pediatric septic shock; the 2026 SSC guideline similarly supports bolus fluid titrated to clinical markers, stopping for shock resolution or overload. [\[3\]](#cite-3 "Reference [3]") If septic shock remains possible, obtain cultures if they do not delay therapy and start broad-spectrum antimicrobials ideally within 1 hour of recognition. If shock persists after initial fluid or fluid overload appears, start vasoactive support; current guidance allows either epinephrine or norepinephrine as first-line vasoactive therapy, guided by physiology and local expertise. [\[2\]](#cite-2 "Reference [2]") The Preventable Failure: PEWS, Bias, and Handoff ------------------------------------------------ ### What PEWS should have caught Most PEWS tools combine respiratory, cardiovascular, perfusion, oxygenation, temperature, and neurologic data. Commonly tracked variables include HR, RR, BP, SpO2, level of consciousness, and capillary refill time. [\[4\]](#cite-4 "Reference [4]") This patient had at least three high-risk domains before collapse: DomainConcerning featureCardiovascularHR 190, later weak pulses and hypotensionRespiratoryRR 65, retractions, increasing oxygen needPerfusion/neurologicmottling, delayed refill, obtundation ### The cognitive trap The nurse’s explanation was anchoring bias with premature closure. Fever and agitation were accepted as the story, despite contradictory data: temperature 37.5°C and sustained extreme tachycardia. The safer cognitive move is to ask, what finding would make my current explanation wrong? ### The handoff miss I-PASS would have forced two missing steps: situation awareness with contingency planning, and synthesis by receiver. AHRQ describes synthesis as the receiver summarizing, asking questions, and restating key actions. [\[5\]](#cite-5 "Reference [5]") A safer handoff would sound like: - Watcher: bronchiolitis, still compensating - If HR stays above 180, RR exceeds 60, SpO2 falls below 92%, perfusion worsens, or mental status changes, evaluate at bedside immediately - Consider HFNC, blood gas/lactate, PICU call, and sepsis evaluation if perfusion changes Debrief and Just Culture ------------------------ A hot debrief occurs minutes to hours after the event, while memory and emotion are fresh. It should identify immediate safety issues and support staff. A cold debrief occurs days to weeks later, incorporating chart review, monitoring data, PEWS performance, staffing, escalation pathways, and action items. [\[6\]](#cite-6 "Reference [6]") Just Culture should not mean no accountability. It separates human error, at-risk behavior, and reckless behavior, then matches response to behavior and system context. The likely response here is coaching, escalation-rule redesign, and PEWS reliability work unless review shows conscious disregard of a known substantial risk. [\[7\]](#cite-7 "Reference [7]") Key Points for Board Exams -------------------------- - Hypotension in infants is late decompensated shock. - Cool extremities, delayed refill, weak pulses, and hypotension indicate cold shock physiology. - Lactate rises when oxygen delivery fails to meet tissue demand; interpret it with perfusion signs. - Initial stabilization: oxygen/ventilation, IV/IO access, crystalloid aliquots with reassessment. - I-PASS synthesis by receiver is the read-back step that verifies understanding. - PEWS is only useful if abnormal scores trigger bedside assessment and escalation. Clinical Application -------------------- The board answer is not just 20 mL/kg fluid. The safer answer is recognition of deterioration, rapid support of oxygen delivery, access, cautious resuscitation, early antibiotics when septic shock is suspected, and a system that makes the next missed tachycardia harder to ignore. Frequently Asked Questions ---------------------------- ### When should bronchiolitis stop being treated as routine ward disease? When perfusion, mental status, oxygen requirement, respiratory effort, or vital-sign trajectory worsens. Sustained tachycardia out of proportion to fever should trigger bedside reassessment. ### What shock type is suggested by cool extremities and delayed capillary refill? This pattern suggests cold shock physiology, typically low cardiac output with increased peripheral vasoconstriction. In an infected child, classify it as suspected septic shock until another cause is proven. ### Should lactate alone determine resuscitation decisions? No. Lactate supports concern for impaired oxygen delivery, but management should integrate pulses, capillary refill, mental status, BP, urine output, respiratory status, and serial reassessment. ### What part of I-PASS prevents misunderstood contingency plans? Synthesis by receiver. The receiving clinician summarizes the plan, asks clarifying questions, and restates key action items and triggers. ### How should a Just Culture review address the missed escalation? It should examine whether the behavior was human error, at-risk behavior, or reckless behavior, while also fixing system vulnerabilities such as unclear watcher criteria and weak PEWS escalation. References (8) ------------------ 1. 1. [ AAP Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis ](https://publications.aap.org/pediatrics/article/134/5/e1474/75848/Clinical-Practice-Guideline-The-Diagnosis) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026 ](https://sccm.org/survivingsepsiscampaign/guidelines-and-resources/surviving-sepsis-campaign-pediatric-guidelines) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ 2025 AHA/AAP Pediatric Advanced Life Support Guidelines ](https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/pediatric-advanced-life-support) [↩](#cite-ref-3-1 "Back to text") 4. 4. [ www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/medical-paediatrics/paediatric-early-warning-score-pews ](https://www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/medical-paediatrics/paediatric-early-warning-score-pews/) [↩](#cite-ref-4-1 "Back to text") 5. 5. [ www.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.html?refID=BAPTAi ](https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.html?refID=BAPTAi) [↩](#cite-ref-5-1 "Back to text") 6. 6. [ pmc.ncbi.nlm.nih.gov/articles/PMC7351457 ](https://pmc.ncbi.nlm.nih.gov/articles/PMC7351457/) [↩](#cite-ref-6-1 "Back to text") 7. 7. [ AHRQ PSNet: Making Just Culture a Reality ](https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach) [↩](#cite-ref-7-1 "Back to text") 8. 8. [ AHRQ TeamSTEPPS Tool: I-PASS ](https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.html) Study pathway Practice Pediatrics the way boards test ----------------------------------------- - Age‑specific differentials and management - Growth, development, and immunizations - Target weak areas with smart review Free 5-day trial No credit card required. 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