Shock Shock Definition • Inadequate tissue perfusion and oxygenation to meet metabolic needs Shock Causes of shock • Inadequate blood volume or oxygen-carrying capacity • Inappropriate distribution of blood volume and flow • Impaired cardiac contractility • Obstructed blood flow Shock Classification of shock by type • Hypovolemic/Hemorrhagic • Distributive • Cardiogenic • Obstructive Shock Classification of shock by severity • Compensated • Hypotensive Shock Compensatory mechanisms • Tachycardia • Increase in systemic vascular resistance • Increase in strength of cardiac contraction • Increase in venous smooth muscle tone Shock Clinical signs of compensated shock • Tachycardia • Weak peripheral pulses • Delayed capillary refill • Alteration in pulse pressure • Cold, pale, mottled and diaphoretic skin • Decreased urine output • Decreased gut perfusion Shock Clinical signs of hypotensive shock • Systolic blood pressure < 70 + (child’s age in years x 2) mmHg • Decreased level of consciousness • Signs and symptoms of multiple organ dysfuction Calculation of normal blood pressure in children > 1 years based on age • • Systolic blood pressure = 80 + (child’s age in years x 2) mmHg Diastolic blood pressure = 2/3 of systolic Shock Pediatric shock • Good ability to compensate due to increased systemic vascular resistance and impaired peripheral perfusion • Hypotension is a late sign of shock • Hypotension becomes evident after loss of 30% of intravascular volume • Rapid progression and decompensation Shock Shock Clinical signs of worsening shock • Progressive tachypnea and tachycardia changing to bradypnea and bradycardia • Loss of peripheral pulses • Lethargy • Bradycardia and weak central pulses in a child with signs of shock are ominous signs of impending cardiac arrest Shock General steps of management • Positioning • Airway and breathing • Vascular access • Fluid resuscitation • Frequent reassessment • Laboratory studies • Medications • Consultations Shock Vascular Access for management of shock • Intravenous route • Intraosseous route Shock Intraosseous route is indicated • When establishment of intravenous access is delayed more than 90 seconds or after 3 unsuccessful attempts of peripheral catheter placement • In cardiac arrest or severe shock cases • Can be achieved in children of all ages usually in 30-60 seconds • All fluids including blood products and medications can be delivered with same concentration, amount and rate as with intravenous access • Blood obtained during intraosseous needle insertion can be sent for lab. Tests and crossmatch Shock Shock Shock Contraindications • Local infection • Local burn • Fracture or crush injury near the access site • Osteogenesis imperfecta • Previous attempts in the same bone Shock Complications • Fracture • Subcutaneous and/or subperiostal infiltration of fluids • Compartment syndrome • Cellulites, abscess • Osteomielytis Shock Causes of Hypovolemic shock • Diarrhea • Vomiting • Hemorrhage – internal and external • Large burn • Osmotic diuresis – DKA • Third space losses Shock Clinical signs and symptoms • “Silent” tachypnea • Tachycardia • Weak or absent peripheral pulses • Normal or weak central pulses • Narrow pulse pressure • Delayed capillary refill • Hypotension • Cool, pale and mottled skin • Changes in level of consciousness • Oliguria Shock Management of non-hemorrhagic hypovolemic shock • Recognition and treatment of the source of fluid loss • Adults: 1-2 liters of isotonic crystalloid solution • Children: 20 ml/kg boluses of isotonic crystalloid solution • Reassessment of the patient vital signs and condition after each bolus • Replacement of ongoing fluid losses • Albumin or other colloids in patients with large third-space losses Shock Management of hemorrhagic shock • Recognition of the source of blood loss • Unit of Packed red blood cells : FFP : Platelets = 1 : 1 : 1 or 2 : 1 : 1 in adult • 10 ml/kg blood transfusion in children • Definitive control of bleeding Shock Distributive shock • Septic • Anaphylactic • Neurogenic Shock Signs of warm shock • Decrease in systemic vascular resistance due to vasodilation • Hypotension • Wide pulse pressure • Increased skin perfusion • Warm extremities • Bounding peripheral pulses • Brisk capillary refill Shock Signs of cold shock • Increase in systemic vascular resistance due to vasoconstriction • Hypotension • Narrow pulse pressure • Decreased skin perfusion • Cold extremities • Weak or absent peripheral pulses • Delayed capillary refill Shock Signs and symptoms of anaphylactic shock • Anxiety or agitation • Tachycardia • Hypotension • Wide pulse pressure • Urticaria • Angioedema • Respiratory distress with stridor or wheezing • Nausea and vomiting • Abdominal spasms Shock Management of anaphylactic shock • ABCs • Epinephirine 1 : 1000 IM - Adults: 0.5 mg - Children 0.01 mg/kg, max. 0.5 mg - may be repeated in 10-15 minutes if required • Bolus of isotonic crystalloid • Epinephrine infusion • Albuterol inhalation • Diphenhidramine 1 mg/kg • Systemic steroids Shock Signs and symptoms of neurogenic shock • Hypotension • Wide pulse pressure with low diastolic pressure • Normal heart rate or bradycardia • Warm extremities • Pink skin • Brisk capillary refill Shock Management of neurogenic shock • Trendelenburg position if not contraindicated • Bolus of isotonic crystalloid solution • Vasopressor infusion (Epinephrine or Norepinephrine) Shock Causes of cardiogenic shock • Miocardial infarction • Congenital heart disease • Myocarditis • Cardiomyopathy • Arrhythmias • Sepsis • Poisoning or drug toxicity • Myocardial injury Shock Signs and symptoms of cardiogenic shock • Tachypnea • Tachycardia • Increased work of breathing • Pulmonary edema • Normal or low blood pressure with narrow pulse pressure • Weak peripheral pulses • Delayed capillary refill • Change in level of consciousness • Cold, pale and mottled skin • Oliguria • Signs of congestive heart failure Shock Management of cardiogenic shock • Fluids delivered carefully with close monitoring of CV function • Supplementary oxygen • Non-invsive or invasive positive pressure ventilation • Inotropic, vasodilator agents • Diuretics • Sedation and analgesia to decrease metabolic demands • Expert consultation Shock Causes of obstructive shock • Cardiac tamponade • Tension pneumothorax • Ductal-dependent congenital heart diseases • Massive pulmonary embolism Shock Complications of shock • Acute renal failure • Acute respiratory distress syndrome (ARDS) • Disseminated intravascular coagulation (DIC) • Multiple organ dysfunction syndrome (MODS) Shock Therapeutic end points • Normal heart rate and blood pressure for age • Normal pulses • Capillary refill < 2 seconds • Warm extremities • Normal mental status • Urine output > 1 ml/kg/hour • Decreased serum lactate • Reduced base deficit • Central venous oxygen saturation (SCVO2) > 70% Thank you for your attention
