This chapter discusses the diagnosis, evaluation and management of shock. It presents special circumstances which make diagnosis and management of shock difficult in pediatric and pregnant patients. Shock should be suspected when patients present with a constellation of signs including ill-appearance, tachycardia, tachypnea, hypotension, and oliguria. The principles of shock management include specific therapy for treating the underlying cause, and general therapy to manage the shock syndrome. Recognition of shock is difficult due to variations in age-dependent vital signs, difficulty in assessing mental status, and the non-specificity of early manifestations of shock such as irritability and poor feeding. Elderly patients experience significantly more morbidity and mortality from all causes of shock due to their limited ability to augment cardiac output and maintain vascular tone. Elderly patients often have multiple comorbidities or use multiple medications that distort the diagnosis and management of shock.

Anesthesiologists should choose to involve children in medical decision-making with the ethical objective of enhancing the child's self-determination, while keeping the child engaged in their care. Anesthesiologists can use the patient's age as a first approximation of a patient's cognitive and emotional development. This chapter discusses the issues raised by incorporating the ethical concept of pediatric patient assent into the traditional process of parental (surrogate) informed consent. Competency is a legal term while decision-making capacity is the ability to make a specific decision at a specific time. It is important to resolve disagreements among the pediatric patient-parent-physician triad about the appropriate clinical plan. Response to requests for nondisclosure by parents must weigh the goal of the best Znterests of the patient. Emancipated minor and mature minor status pose distinct ethical and practical issues. Confidentiality must be honored, and failure to do so may be harmful to the patient.

Plain extremity radiographs are indicated in pediatric patients with significant mechanism of injury, pain, limitation of use or motion, or physical exam evidence of deformity, swelling, or tenderness. The joint above and below the site of injury should be examined, and radiographs of adjacent joints should be obtained when indicated. Pediatric extremities consist of growing bones and ossifications centers, with wide variability in normal-appearing bones based on age. As the physic itself is radiolucent, physeal fractures are not always evident on initial plain radiographs. Minimum views of the extremity should include anteroposterior (AP) and lateral. Negative initial plain radiographs do not exclude a Salter-Harris type 1 physeal fracture. If a pediatric patient has negative films but significant swelling or point tenderness along the physic of a bone, a physeal fracture and splint can be assumed accordingly. The incidence of sprains and dislocations are less common in children than in adults.

This chapter focuses on the use of laparoscopy in treatment and diagnosis of patients with pelvic pain, adnexal masses, and pelvic inflammatory disease (PID). A discussion of incidental appendectomy in these patients will also be presented. The decision to perform incidental appendectomy is based on the premise that the appendix is a vestigial, functionless organ, with the potential only to contribute to pathological change. PID can have devastating consequences to adolescent females. With the advent of in vitro fertilization, surgeons should attempt to perform the most conservative surgery that is safely possible, in order to maintain the option of future childbearing. Diagnosis of endometriosis should not be delayed in adolescents. A delay may not only postpone symptomatic relief but also worsen the patient's future fertility and allow the disease to progress. Laparoscopy, as it applies to the pediatric and adolescent population, is a relative newcomer to the field.