Pediatric Shock

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Pediatric Shock
Recognition, Classification and Initial
Management
Critical Concepts Course
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Introduction

• Shock is a syndrome that results from inadequate
  oxygen delivery to meet metabolic demands
• Oxygen delivery (DO2 ) is less than Oxygen
  Consumption (lt VO2)
• Untreated this leads to metabolic acidosis, organ
  dysfunction and death

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Oxygen Delivery

• Oxygen delivery Cardiac Output x Arterial
  Oxygen Content
• (DO2 CO x CaO2)
• Cardiac Output Heart Rate x Stroke Volume (CO
  HR x SV)
• SV determined by preload, afterload and
  contractility
• Art Oxygen Content Oxygen content of the RBC
  the oxygen dissolved in plasma
• (CaO2 Hb X SaO2 X 1.34 (.003 X PaO2)

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Stages of Shock

• Compensated
• Vital organ function maintained, BP remains
  normal.
• Uncompensated
• Microvascular perfusion becomes marginal. Organ
  and cellular function deteriorate. Hypotension
  develops.
• Irreversible

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Clinical Presentation

• Early diagnosis requires a high index of
  suspicion
• Diagnosis is made through the physical
  examination focused on tissue perfusion
• Abject hypotension is a late and premorbid sign

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Initial Evaluation Physical Exam Findings of
Shock

• Neurological Fluctuating mental status, sunken
  fontanel
• Skin and extremities Cool, pallor, mottling,
  cyanosis, poor cap refill, weak pulses, poor
  muscle tone.
• Cardio-pulmonary Hyperpnea, tachycardia.
• Renal Scant, concentrated urine

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Initial Evaluation Directed History

• Past medical history
• heart disease
• surgeries
• steroid use
• medical problems
• Brief history of present illness
• exposures
• onset

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Differential Diagnosis of Shock

• Cardiogenic
• Myocardial dysfunction
• Dysrrhythmia
• Congenital heart disease
• Obstructive
• Pneumothorax, CardiacTamponade, Aortic Dissection
• Dissociative
• Heat, Carbon monoxide, Cyanide
• Endocrine

• Hypovolemic
• Hemorrhage
• Fluid loss
• Drugs
• Distributive
• Analphylactic
• Neurogenic
• Septic

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Differential Diagnosis of Shock

• Precise etiologic classification may be delayed
• Immediate treatment is essential
• Absolute or relative hypovolemia is usually
  present

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Neonate in Shock Include in differential

• Congenital adrenal hyperplasia
• Inborn errors of metabolism
• Obstructive left sided cardiac lesions
• Aortic stenosis
• Hypoplastic left heart syndrome
• Coarctation of the aorta
• Interrupted aortic arch

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Management-General

• Goal increase oxygen delivery and decrease
  oxygen demand
• For all children
• Oxygen
• Fluid
• Temperature control
• Correct metabolic abnormalities
• Depending on suspected cause
• Antibiotics
• Inotropes
• Mechanical Ventilation

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Management-General

• Airway
• If not protected or unable to be maintained,
  intubate.
• Breathing
• Always give 100 oxygen to start
• Sat monitor
• Circulation
• Establish IV access rapidly
• CR monitor and frequent BP

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Management-General

• Laboratory studies
• ABG
• Blood sugar
• Electrolytes
• CBC
• PT/PTT
• Type and cross
• Cultures

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Management-Volume Expansion

• Optimize preload
• Normal saline (NS) or lactated ringers (RL)
• Except for myocardial failure use 10-20ml/kg
  every 2-10 minutes. Reasses after every bolus.
• At 60ml/kg consider ongoing losses, adrenal
  insufficiency, intestinal ischemia, obstructive
  shock. Get CXR. May need inotropes.

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Fluid in early septic shock Carcillo, et al,
JAMA, 1991

• Retrospective review of 34 pediatric patients
  with culture septic shock, from 1982-1989.
• Hypovolemia determined by PCWP, u.o and
  hypotension.
• Overall, patients received 33 cc/kg at 1 hour and
  95 cc/kg at 6 hours.
• Three groups
• 1 received up to 20 cc/kg in 1st 1 hour
• 2 received 20-40 cc/kg in 1st hour
• 3 received greater than 40 cc/kg in 1st hour
• No difference in ARDS between the 3 groups

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Fluid in early septic shock Carcillo, et al,
JAMA, 1991
Group 1 (n 14) Group 2 (n 11) Group 3 (n 9)
Hypovolemic at 6 hours -Deaths 6 6 2 2 0 0
Not hypovolemic at 6 hours -Deaths 8 2 9 5 9 1
Total deaths 8 7 1
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Inotropes and Vasopressors

• Lack of history of fluid losses, history of heart
  disease, hepatomegaly, rales, cardiomegaly and
  failure to improve perfusion with adequate
  oxygenation, ventilation, heart rate, and volume
  expansion suggests a cardiogenic or distributive
  component.
• Consider Appropriate inotropic or vasopressor
  support.

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Hypovolemic Shock

• Most common form of shock world-wide
• Results in decreased circulating blood volume,
  decrease in preload, decreased stroke volume and
  resultant decrease in cardiac output.
• Etiology Hemorrhage, renal and/or GI fluid
  losses, capillary leak syndromes

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Hypovolemic Shock

• Clinically, history of vomiting/diarrhea or
  trauma/blood loss
• Signs of dehydration dry mucous membranes,
  absent tears, decreased skin turgor
• Hypotension, tachycardia without signs of
  congestive heart failure

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Hemorrhagic Shock

• Most common cause of shock in the United States
  (due to trauma)
• Patients present with an obvious history (but in
  child abuse history may be misleading)
• Site of blood loss obvious or concealed (liver,
  spleen, intracranial, GI, long bone fracture)
• Hypotension, tachycardia and pallor

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Hypovolemic/Hemorrhagic Shock Therapy

• Always begin with ABCs
• Replace circulating blood volume rapidly start
  with crystalloid
• Blood products as soon as available for
  hemorrhagic shock (Type and Cross with first
  blood draw)
• Replace ongoing fluid/blood losses treat the
  underlying cause

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Septic Shock
SIRS/Sepsis/Septic shock
Mediator release exogenous endogenous
Maldistribution of blood flow
Cardiac dysfunction
Imbalance of oxygen supply and demand
Alterations in metabolism
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Septic Shock Warm Shock

• Early, compensated, hyperdynamic state
• Clinical signs
• Warm extremities with bounding pulses,
  tachycardia, tachypnea, confusion.
• Physiologic parameters
• widened pulse pressure, increased cardiac ouptut
  and mixed venous saturation, decreased systemic
  vascular resistance.
• Biochemical evidence
• Hypocarbia, elevated lactate, hyperglycemia

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Septic Shock Cold Shock

• Late, uncompensated stage with drop in cardiac
  output.
• Clinical signs
• Cyanosis, cold and clammy skin, rapid thready
  pulses, shallow respirations.
• Physiologic parameters
• Decreased mixed venous sats, cardiac output and
  CVP, increased SVR, thrombocytopenia, oliguria,
  myocardial dysfunction, capillary leak
• Biochemical abnormalities
• Metabolic acidosis, hypoxia, coagulopathy,
  hypoglycemia.

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Septic Shock

• Cold Shock rapidly progresses to mutiorgan system
  failure or death if untreated
• Multi-Organ System Failure Coma, ARDS, CHF,
  Renal Failure, Ileus or GI hemorrhage, DIC
• More organ systems involved, worse the prognosis
• Therapy ABCs, fluid
• Appropriate antibiotics, treatment of underlying
  cause

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Cardiogenic Shock

• Etiology
• Dysrhythmias
• Infection (myocarditis)
• Metabolic
• Obstructive
• Drug intoxication
• Congenital heart disease
• Trauma

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Cardiogenic Shock

• Differentiation from other types of shock
• History
• Exam
• Enlarged liver
• Gallop rhythm
• Murmur
• Rales
• CXR
• Enlarged heart, pulmonary venous congestion

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Cardiogenic Shock

• Management
• Improve cardiac output
• Correct dysrhthymias
• Optimize preload
• Improve contractility
• Reduce afterload
• Minimize cardiac work
• Maintain normal temperature
• Sedation
• Intubation and mechanical ventilation
• Correct anemia

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Distributive Shock

• Due to an abnormality in vascular tone leading to
  peripheral pooling of blood with a relative
  hypovolemia.
• Etiology
• Anaphylaxis
• Drug toxicity
• Neurologic injury
• Early sepsis
• Management
• Fluid
• Treat underlying cause

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Obstructive Shock

• Mechanical obstruction to ventricular outflow
• Etiology Congenital heart disease, massive
  pulmonary embolism, tension pneumothorax, cardiac
  tamponade
• Inadequate C.O. in the face of adequate preload
  and contractility
• Treat underlying cause.

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Dissociative Shock

• Inability of Hemoglobin molecule to give up the
  oxygen to tissues
• Etiology Carbon Monoxide poisoning,
  methemoglobinemia, dyshemoglobinemias
• Tissue perfusion is adequate, but oxygen release
  to tissue is abnormal
• Early recognition and treatment of the cause is
  main therapy

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Hemodynamic Variables in Different Shock States
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Recognition and Classification
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Initial Management of Shock
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Final Thoughts

• Recognize compensated shock quickly- have a high
  index of suspicion, remember tachycardia is an
  early sign. Hypotension is late and ominous.
• Gain access quickly- if necessary use an
  intraoseous line.
• Fluid, fluid, fluid - Administer adequate amounts
  of fluid rapidly. Remember ongoing losses.
• Correct electrolytes and glucose problems
  quickly.
• If the patient is not responding the way you
  think he should, broaden your differential, think
  about different types of shock.

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References, Recommended Reading, and
Acknowledgments

• Uptodate Initial Management of Shock in
  Pediatric patients
• Nelsons Textbook of Pediatrics
• Some slides based on works by Dr. Lou DeNicola
  and Dr. Linda Siegel for PedsCCM
• American Heart Association PALS guidelines