Circulatory system failure to supply oxygen and nutrients to meet cellular metabolic demands .

Classification and causes:
Hypovolemic
Distributive
Cardiogenic
Obstructive dissociative

Stroke Volume
Cardiac Output
Blood
Pressure
Systemic Vascular
Resistance
Heart Rate
Myocardial
Contractility
Preload
Afterload
Textbook of Pediatric Advanced Life Support, 1988

Cardiac Output
CO = HR x SV
HR responds the quickest
SV is a function of three variables : preload,
After load, myocardial contractility
A noncompliant heart cannot increase SV

1-Cardiac Output
2-Clinical Assessment peripheral perfusion
Temperature capillary refill urine output
Mentation acid-base status

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Definition:
Decreased circulating blood volume.
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Common causes:
Hemorrhage
Diarrhea
Diabetes insipidus
Diabetes mellitus
Burns
Adrenogenital syndrome

 Definition
Vasodilation and decreased preload
Common causes:
Sepsis
Anaphylaxis
Spinal injury
Drug intoxication

 Decreased myocardial contractility
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Common causes:
Congenital heart disease
Severe heart failure
Arrhythmia hypoxic ischemic injuries
Cardiomyopathy
Myocarditis
Drug intoxication kawasaki

Definition
Mechanical obstruction to ventricular outflow.
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Common causes:
Cardaic tamponade
Massive pulmonary embolus
Tension pneumothorax
Cardiac tumor

Definition
 Oxygen not released from hemoglobin.
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1.
2.
Common causes
Carbon monoxide poisoning methemoglobinemia

 Cardiovascular support
 Fluid resuscitation
 Cardiotonic and vasodilator therapy
 Respiratory support
 Renal salvage

Cardiovascular Changes in Shock
Type Preload Afterload Contractility
Cardiogenic   
Hypovolemic   No change
Distributive
Septic early late
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 Regardless of the cause: ABC
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 First assess airway patency ventilation
 then circulatory system

 Respiratory Performance
 Respiratory rate and pattern
 work of breathing
 oxygenation (color)
 level of alertness
 Circulation
 Heart rate, BP, perfusion, and pulses, liver size
 CVP monitoring may be helpful

 Early Signs of Shock
 sinus tachycardia.
 delayed capillary refill.
 fussy, irritable.
 Late Signs of Shock

 Late Signs of Shock
 bradycardia
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 altered mental status (lethargy, coma) hypotonia, decreased DTR ’s
 Cheyne-Stokes breathing
 hypotension is a very late sign

Cardiovascular Assessment
(con)
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CNS Perfusion
 Recognition of parents
 Reaction to pain
 Muscle tone
 Pupil size
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Renal Perfusion
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UOP >1cc/kg/hr

Cardiovascular Assessment
(con)
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Skin Perfusion
 Capillary refill time
 Temperature
 Color
 Mottling

 The key therapy is the recognition of shock in its early state.
 Treating the signs and symptoms.
 Minimize cadiopulmonary work.
 Ensuring cardiac output blood pressure and gas exchange

 Mainstay of therapy is fluid .
 Goals:
1.
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Restore intravascular volume
Correct metabolic acidosis
Treat the cause

 Degree of dehydration often underestimated
 Reassess perfusion, urine output, vital signs...
 Isotonic crystalloid is always a good choice
 20 to 50 cc/kg rapidly if cardiac function is normal
 NS can cause a hyperchloremic acidosis

Other Studies
 Look for etiology of shock.
 Evaluate hemoglobin, hematocrit, and platelet count.
 Shock from any etiology can lead to DIC and end organ damage

 CBC, PT, INR, PTT, Fibrinogen, Factor V,
Factor VIII
 Check LFT ’s, follow CNS and pulmonary status

 Goal of therapy is; identification evaluation and treatment of shock in its earliest stage
 Successful resuscitation depends on early and judicious intervention
 Initial priorities are for the ABC ’s

 Fluid resuscitation begins with 20cc/kg of crystalloid or 10cc/kg of colloid
 Subsequent treatment depends on the etiology of shock and the patient ’s homodynamic condition

Related infection and shock
 Infection
 Bacteremia
 Systemic inflammatory response syndrome :
(2 or>2 of following)
(T>38
HR>90
RR>20
WBC>12000 or<4000)

Related infection and shock
 Sepsis:
Systemic response to infection
 Sever sepsis: sepsis + organ dysfunction
(hypo perfusion, lactic acidosis, oliguria,or an acute alter mental status)

Related infection and shock
 Septic shock: sepsis +hypotention despid adequate fluid
 Hypotention: systolic<9 or >4reduction
 Multiple organ dysfuntion

 Disruption 3 key function of skin
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Regulation of heat loss presevation of body fluid
Barrier of the infection

 Release inflammatory and vasoactive mediators
 capillary permeability increase
 Decrease plasma volume and cardiac output
 Shock is common if borne > 10% -12%

3.
4.
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2.
Depth of injury
Percent of body surface area involved
Location of the burn
Association with other injuries

1-First – degree:
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Red, painful dray
Superficial and limited to epidermis.
Heal in 3-6 days

2-Second degree:
 Partial-thicking
1superficial ( red,painful, blister ) heal in 10-
21 days
2-deep dermal ( pale ,painful, yellow ) heal in 3 weeks , scarring

3-Third –degree:
 Full thickness ,require grafts if >1 cm
 Avascular and coagulation necrosis
4- fourth – degree:
 Involve underling facia, muscle or bone

 Sever burn:
>15%Body surface involves face or prineum
2 and 3 –degree burns hands or feet circumfrential burn of extermity inhalation injury

Percent of body surface area involved
 Each upper extremity 9%
 each lower extremity 18%
 Posterior trunk 18%
 Anterior trunh 18%
 Head 9% and prinium1%
Location is important :
 Face, eyes, ears, feet, prinium, hand ,full thickness

 decision is based on :
Extent of burn
(% burn)
, body surface
(location), type of burn, associated injure , medical complication
,availability ambulatory management
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Stop the burning process
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Fluid and electrolyte support
(systemic copillary
leak)

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Significant burn , Second 24 hr dextrose in0.25 normal bolus 20cc/kg lactated Ringer
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Total fluid is 2-4cc/kg/percent burn/24 hr
(
Half in first 8 hr
) that equal 1cc/kg/hr of urine saline
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Colloid therapy is needed if burn >30% bs and provided after 24 hr with crystalloid

 Nutritional support:
( burn produce hypermetabolic response that sedation and analgesic can decrease)
In critical burn parenteral nutrition
Enteral feeding résumé on 2-3 days

 Wound care:
 Relief any pressure on cerculation
 Covered with sulfadiazin
 Graft
 Tetanus toxoid in incomplete immunization

 Extended of burn > 10% in children
 Body surface area involved:
Face ,neck, both hands, both feet ,prineum
 Type of burn; electrical contact ,chemical
 Association injuries;
Soft tissue trauma, fractures,smoke inhalation head injury .

 Complicating medical problems
Diabetes ,heart disease, pulmonary disease, ulcer history.
 Social problem .
Suspected child abuse or neglect, self infected burn, psycologic problems

 Sepsis ( avoid prophylactic antibiotic)
 Hypovolemia, hypothermia
 laryngeal edema
 carbon monoxide injury
(100% o2,hyper baric o2)
 cardic disfunction
 gasteric ulcer

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 compartment syndrome contracture hyper metabolic state renal failure anemia psychological trauma pulmonary infiltration,pulmonary edema, pneumonia,bronchospasm