Critical Concepts:
Shock
Inadequate peripheral perfusion where
oxygen delivery does not meet
metabolic demand
 Adult vs Pediatric Shock - Same
causes/different frequencies

Pediatric Shock

Hypovolemia
 Most common cause of pediatric shock
 Small blood volumes (80cc/kg)

Sepsis
 Second most common cause of pediatric
shock
 Immature immune system
Pediatric Shock

Cardiogenic
 Primary pump failure – congenital heart
disease
 Secondary failure from:
○ Hypoxia
○ Acidosis
○ Hypoglycemia
○ Hypothermia
○ Drug toxicity
Pediatric Shock

Neurogenic
 Rare
 Low incidence associated with low pediatric
spinal cord trauma rates
Pediatric Shock
Early shock - Very difficult to detect
 Pediatric cardiovascular system
compensates well


Early Signs/Symptoms




Tachycardia - carry chart of normals
Slow capillary refill ( > 2 seconds)
Pale or mottled skin, cool extremities
Tachypnea
Pediatric Shock

Late Signs/Symptoms
 Weak or absent peripheral pulses
 Decreasing level of consciousness
 Hypotension

Hypotension = Pre-arrest State
Pediatric Shock Management
Initial assessment may detect shock, but
not its cause
 When in doubt, treat for hypovolemia

Shock Management

Airway
 Open, clear, maintain
 Non-invasive (chin lift, jaw thrust)
 Invasive (endotracheal intubation)
 Trauma patient - ? C-spine injury
Shock Management

Breathing
 100% oxygen indicated for all shock
 Ventilation
○ Reduce work of breathing
○ Do not “fight” patient
Shock Management

Circulation
 Apply cardiac monitor
 Control obvious hemorrhage
 Elevate lower extremities
Shock Management

Fluid Resuscitation
 Obtain Access quickly
 Consider intraosseous access
 Fluid bolus: 20 ml/kg isotonic fluid
 Most common error--Too LITTLE fluid
 Reassess for:
○ Improved perfusion
○ Respiratory distress
 Check blood glucose
○ Give D25W if D-stick < 40 - 60
Disorders of Hydration

Causes
 Vomiting
 Diarrhea
 Fever
 Poor oral intake
 Diabetes mellitus
Disorders of Hydration

Mild dehydration ( <5% weight loss)
 Mild increased thirst
 Slight mucous membrane dryness
 Slight decrease in urinary frequency
 Slight increase in pulse rate
Disorders of Hydration

Moderate dehydration
(5 - 10% weight loss)
 Moderate increase in thirst
 Very dry, “beefy red” mucous




membranes
Decrease in skin turgor
Tachycardia
Oliguria, concentrated urine
Sunken eyes
Disorders of Hydration

Severe dehydration
- 15% weight loss)








Severe thirst
Tenting of skin
No tears when crying
Weak, thready pulses
Marked tachycardia
Sunken fontanelle
Hypotension
Decrease in LOC
(10
Disorders of Hydration

Management
 Oxygen
 20 cc/kg boluses LR
 Repeat boluses as needed to
○ Restore peripheral pulses
○ Decrease tachycardia
○ Improve LOC
Remember that hypotension is a late
and ominous finding!
 Reassess frequently

Normal upper airway anatomy
Tonsils
Epiglottis
Esophagus
Tongue
Trachea
Larynx
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Typical causes of distress

Upper airway





Croup
Retropharyngeal abscess
Epiglottitis
Foreign body aspiration
Lower airway




ACCT4Kids
Reactive airway disease / asthma
Bronchiolitis
Pneumonia
Pneumothorax
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Why are kids different?




Obligate nosebreathers
Tongue relatively
larger
Higher larynx (C3-C4
versus C6)
Narrowing of airway
causes exponential
rise of airway
resistance
ACCT4Kids



Less elasticity of
alveoli
Lower FRC
Diaphragm
 Flatter
 Muscle fibers more
vulnerable to fatigue

Chest wall
 More compliant
 Ribs more horizontal
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Signs & symptoms of distress








Nasal flaring
Hypoventilation,
apnea
Stridor
Grunting
Wheezing
Pallor, ashen color
 WOB
Tachypnea
ACCT4Kids








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Cyanosis
Head bobbing
Tripod positioning
Retractions
 Level of
consciousness
 Air movement
Acidosis
Hypercapnea
Croup (LaryngoTracheoBronchitis)




Most severe in kids 6 mo - 3 years old
Males
Winter months
Associated illnesses
 Ear infection
 Pneumonia
 Organisms: parainfluenza types 1, 2 & 3,
adenovirus, RSV, influenza
ACCT4Kids
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Croup symptoms







ACCT4Kids
URI symptoms X 1-3
days
Low grade fever
“Barking” cough,
hoarseness
Inspiratory stridor
Worse at night
Prefer to sit up
Aggravated by agitation
& crying
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Croup diagnosis
Clinical diagnosis
 Does not require
neck X-ray

Steeple sign
 Consider X-ray in
patients with atypical
presentation or
clinical course

ACCT4Kids
“Steeple sign”
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Croup treatment
Position of comfort, with parent
 Dexamethasone 0.6 mg/kg IV/IM
Hypopharnyx
 Epi neb
 Heliox
Narrow air
column
 SQ Epi
Trachea
 Cool mist

Steeple sign
ACCT4Kids
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Retropharyngeal abscess



Deep, potential, space of the neck
Children age 6 months to 6 years
Other deep neck abscesses more
frequent in older children & adults
 Parapharyngeal
 Peritonsillar


ACCT4Kids
Potential for airway compromise
Complications secondary to mass effect,
rupture of the abscess, or spread of
infection
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Retropharyngeal abscess symptoms







Fever, chills,
malaise
Decreased appetite
Irritability
Sore throat
Difficulty or pain
swallowing
Jaw stiffness
Neck stiffness
ACCT4Kids




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Muffled voice
“Lump” in the throat
Pain in the back &
shoulders upon
swallowing
Difficulty breathing is
an ominous
complaint that
signifies impending
airway obstruction
Retropharyngeal abscess
ACCT4Kids
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Retropharyngeal abscess

Polymicrobial infection typical
 Gram-positive organisms and anaerobes
predominating
 Gram-negative bacteria possible
 Oropharyngeal flora

Most common cause is group A betahemolytic streptococci
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Retropharyngeal abscess Treatment
Position airway - comfort
Avoid unnecessary manipulation
Monitor, CT of neck, possible OR
Sedation & paralytics can relax airway
muscles, leading to complete
obstruction
 Endotracheal intubation is dangerous
 Abx: clindamycin, cefoxitin, Timentin,
Zosyn, or Unasyn




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Epiglottitis
Acute, rapidly progressive cellulitis of
the epiglottis and adjacent structures
 Before immunization - peak incidence at
3.5 years of age
 Danger of airway obstruction - medical
emergency
 Prompt diagnosis and airway protection
required

ACCT4Kids
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Epiglottitis - signs & symptoms
More acute presentation in young
children than in adolescents or adults
 Symptoms for <24 hrs

 High fever, severe sore throat, tachycardia,
systemic toxicity, drooling, tripod position

ACCT4Kids
Moderate or severe respiratory distress
with inspiratory stridor & retractions
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Epiglottitis - lateral neck film
ACCT4Kids
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Epiglottitis
ACCT4Kids
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Epiglottitis - etiology
Group A Streptococcus
 Other pathogens seen less frequently
include:

 Strep pneumoniae
 Haemophilus parainfluenza
 Staph aureus
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Epiglottitis - Treatment
Position of comfort, with parent
Minimize manipulation
Intubation under controlled
circumstances
 O2 prn, blow-by if not tolerating mask
 Avoid agitation (Do not try to start IV,
obtain blood or examine airway!)
 Consult anesthesia & ENT
 IV for antibiotics, after airway secure



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Foreign body (FB) aspiration

Toddler through preschool age common
 No molar teeth for thorough chewing
 Talking, laughing, and running while eating
Nuts, raisins, sunflower seeds, pieces of
meat and small smooth (grapes, hot dogs,
& sausages)
 Dried foods absorb water

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Foreign Body aspiration
Sudden episode of coughing / choking
while eating with subsequent wheezing
(sometimes unilateral), coughing, or stridor
 Tragic cases occur with total or near-total
occlusion of the airway
 Frequent sites of FB lodgement:

 Usually below vocal cords
 Mainstem bronchi
 Trachea
 Lobar bronchi
ACCT4Kids
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Foreign Body aspiration

Extrathoracic FB:
 Breath sounds are inspiratory

Intrathoracic FB
 Noises are symmetric but more prominent in
central airways
 If FB is beyond the carina, the breath
sounds are usually asymmetric
○ Kid chest transmits sounds well
○ Stethoscope head may be bigger than lung lobes
○ Lack of asymmetry should not dissuade you from
considering the FB diagnosis
ACCT4Kids
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Foreign Body aspiration

Hyperinflation & air-trapping of the
affected lobe(s) is typical
 Best seen with X-ray taken at expiration
 Difficult in little kids

ACCT4Kids
May see soft tissue opacity in proximal
airway
40
Foreign bodies
ACCT4Kids
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FB aspiration
Position of comfort
 Heimlich maneuver, back blows
 BVM prn
 Magill forceps (if object above cords)
 Intubation prn
 Needle cricothyrotomy
 Surgical cricothyrotomy
 Rigid bronchoscopy for FB removal

ACCT4Kids
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Reactive airway disease /
Asthma
ACCT4Kids
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RAD / Asthma - children




<3 years - small intrapulmonary airways
Poor collateral ventilation
Decreased elastic recoil pressure
Partially developed diaphragm
ACCT4Kids
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RAD / Asthma










Identify and remove asthma triggers
Albuterol, nebulized
Ipratopium bromide (Atrovent)
Methylprednisolone (Solumedrol)
Magnesium sulfate
CPAP / BiPAP
Heliox
Epinephrine or terbutaline infusion
May require inubation
At risk for pnuemothorax due to hyperinflation
ACCT4Kids
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Bronchiolitis

Organisms: RSV most common
 Others: parainfluenza, influenza, human
metapneumovirus (hMPV), adenovirus,
mycoplasma





ACCT4Kids
Winter & spring
Males
Typically <2 years old, peak 2-8 mos
Disease more severe in babies 1-3 mo old
Risk factors: Heart disease, BPD,
prematurity, smoking in home
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Bronchiolitis
ACCT4Kids
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Bronchiolitis - symptoms
Apnea, bradycardia
 Desaturations
 Cough, copious secretions
 Tachypnea, tachycardia
 Crackles, wheezing
 Increased WOB, retractions
 Flaring, grunting
 Pallor, cyanosis

ACCT4Kids
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Bronchiolitis - diagnosis

No diagnostic tests needed, but possibly:
 Rapid viral panel (antigen or FA panel)
 Viral cultures
 CXR - hyperinflation, peribronchial cuffing, patchy
atelectasis


Tachypnea, WOB, wheezing
Hx URI
 fever, cough, runny nose, appetite


ACCT4Kids
Apnea (may occur w/o other symptoms)
May be complicated by secondary bacterial
infection
49
Bronchiolitis
Isolation - contact, droplet
 O2, keep sats ≥92%
 Pulmonary toilet, suctioning!
 CPAP / BiPAP
 No steroids
 Nebs largely unhelpful (<1/3)
 Chest PT prolongs hospitalization
 Antibiotics depend on other sxs

ACCT4Kids
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Pneumonia
 Types:
 Bronchopneumonia - lobar
consolidation
 Interstitial - usually viral
 More
common in infants & toddlers
than in adolescents
 Commonly:
 Viral, pneumococcus, Mycoplasma
 In immunocompromised, anything is
possible!
ACCT4Kids
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Pneumonia - symptoms
Cough
 Tachypnea
 Grunting
 Retractions
 Chest pain
 Vomiting, poor feeding, abdominal pain
 Fever depends on type

ACCT4Kids
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Pneumonia
ACCT4Kids
53
Pneumonia – Initial Treatment
O2, keep sats ≥92%
 CPAP, BiPAP
 Antibiotics, if considered bacterial

 Cefotaxime + vancomycin
 Azithromycin
Monitor mental status
 Intubate & ventilate if respiratory failure
 Complications: effusion, abscess

ACCT4Kids
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Pneumothorax
ACCT4Kids
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Pneumothorax radiographs
ACCT4Kids
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Tension PTX
Normal
Lung
Heart
Airleak
R
L
heart
PTX
ACCT4Kids
Tension PTX
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