SHOCK IN CHILDREN

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SHOCK IN CHILDREN

• By
• Dr. Eman Fawzy Halawa
• Lecturer of pediatrics
• Abu el Reesh Specialized Hospital
• Cairo University

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OBJECTIVES

• Define shock
• Describe key differences between the pediatric
  and adult circulatory system and how they affect
  assessment and treatment of shock in children
• Explain how to assess for pediatric shock
• List appropriate interventions for pediatric
  shock

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Before we go anywhere, lets startat the
beginning

• What do you need to maintain a nice garden? WATER
• You need to get the water to the garden
• 4 things
• Water pump
• Release valve
• Hose
• Water amount

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• Pump failure Cardiogenic shock
• Release valve failure Obstructive shock
• Hose failure Distributive shock
• Water failure Hypovolemic shock

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What is Shock?

• Theoretical
• Inability to meet cellular requirements for
• oxygen
• Practical
• When the nurse calls you for a low blood
• pressure

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Hemodynamics
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CARDIAC OUTPUT

• Cardiac Output Heart Rate x Stroke Volume

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Heart rate

• As children are "heart rate dependent", the heart
  rate is the single most important vital sign when
  determining shock.

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Stroke volume

• Stroke volume is the second determinant of
  cardiac output,
• 1) preload (intravascular volume/blood often
  called "venous return"), (the fuel),
• 2) myocardial contractility (heart muscle
  function), (the pump),
• 3) afterload (systemic vascular resistance) (the
  pipe).

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Hypovolemic Shock

• a) Absolute Hypovolemia(water failure)
• water and electrolyte losses (diarrhea, vomiting,
  diabetes insipidus, renal losses, heat stroke,
  intestinal obstruction, burns),
• hemorrhage (trauma, surgery, GI bleeding),
• plasma losses (burns, nephrotic syndrome,
  sepsis, intestinal obstruction, peritonitis.

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Distributive shock (Relative Hypovolemia )

• ?anaphylaxis (antibiotics, blood products,
  insects, vaccines, local anesthetics, foods,
  etc.), ?neurologic injury (head injury, spinal
  shock),
• ? drug intoxication (barbiturates,
  phenothiazines, tranquilizers, antihypertensives),
  
• ? sepsis

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Septic Shock

• a) Bacterial Group A streptococcus,
  Haemophilus influenzae type b, Neisseria
  meningitidis, Streptococcus pneumoniae, Group B
  Streptococcus, Gram negative bacilli (E. coli),
  Staphylococcus aureus. b) Others viral, fungal,
  rickettsial

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Cardiogenic Shock

• Causes
• ? Muscle
• ? Valve
• ? Heart rate
• ?Too fast
• ?Too slow
• ? Poor coordination

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Obstructive Shock

• Causes
• ?Tension pneumothorax
• ? Massive pulmonary embolism
• ? Cardiac tamponade
• ? HOCM

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EARLY SHOCK COMPENSATION

• SYMPATHETIC NERVOUS SYSTEM
• Increased heart rate (one of the first responses
  to shock)
• VASOCONSTRICTION
• Maintains perfusion to vital organs
• INCREASED RESPIRATORY RATE
• Increased oxygen to vital tissues

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LATE SHOCK DECOMPENSATION

• Decreased blood pressure (often falls rapidly)
• Decreased respiratory rate
• Significant alteration in level of consciousness
  Stuporous/Coma

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Shock Assessment in Compensated and Decompensated
Hypovolemic Shock
Compensated
Decompensated Pulse
Tachycardia Marked tachycardia
can progress to
bradycardia Skin White, cool, moist
White, waxy, cold,
marked diaphoresis Blood Pressure
Normal range Lowered Level
of Consciousness Unaltered
Altered, ranging

from disoriented to

coma
Source Prehospital Trauma Life Support Manual,
3rd Edition. National Assn of EMTs, 1994
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BLOOD PRESSURE BY ITSELF IS NOT A GOOD INDICATOR
OF THE PRESENCE OF SHOCK!!!!
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DIFFERENCES IN THE PEDIATRIC CIRCULATORY SYSTEM

• Healthier circulatory system
• Less muscle mass than adults
• Higher metabolic rate, increased oxygen demand
• Greater circulating blood volume per weight
• Greater ability to compensate

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ASSESSMENT OF THE CHILD IN SHOCK

• Across-the-room assessment
• ABC

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• Important historical information and physical
  exam findings must be included when considering
  the clinical manifestations and differential
  diagnosis of shock.

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Historical information asked must include

• 1) age
• 2) preexisting conditions/illness,
• 3) fever,
• 4) vomiting/diarrhea,
• 5) poor feeding,
• 6) urine output,
• 7) lethargy,
• 8) trauma,
• 9) toxic ingestion.

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The physical exam must include

• 1) general appearance/alertness/eye
  contact/activity,
• 2) heart rate,
• 3) tachypnea
• 4) fever
• 5) blood pressure
• 6) skin perfusion, a) capillary refill, b) color,
  c) skin temperature, ,
• 7) oliguria (if an observation period is
  permitted),
• 8) altered mental status, ,

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PLAN AND INTERVENTIONS

• Goal is recognition of shock and restoring
  perfusion to normal
• ABCs
• Keep child warm

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TRIAGE AND TRANSPORT

• Any patient suspected to be in shock is EMERGENT
• Call EMS as soon as shock is
  suspected!!

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Treatment

• 1) oxygenation,
• 2) vascular access,
• 3) fluid administration, and
• 4) drug therapy.

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Oxygenation

• providing 100 oxygen
• assuring adequate hemoglobin, stopping
  hemorrhage, and replacing blood if the hematocrit
  is less than 30.
• Consider endotracheal intubation, but be aware of
  the cardiovascular effects that intubation and
  positive ventilation can cause

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Vascular access

• insertion of a (preferably two) large intravenous
  catheters, and obtaining necessary lab tests
  (CBC, blood culture, electrolytes, BUN,
  creatinine, glucose, calcium, coagulation profile
  and blood gas). If vascular access is difficult
  to obtain, use an intraosseous (IO) device

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Fluids

• Two broad categories related to a shock
• discussion
• Crystalloids
• colloids

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Crystalloids

• Hypo- not helpful for our patient in shock
• D5, 2/3 1/3, ½ NS
• Iso NS, RL
• - Ringers lactate has lower chloride
  concentration vs normal saline
• -tendency of the former to produce a
  non-anion gap metabolic acidosis when
  given in significant amounts
• Hyper mannitol, 3NS

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Colloids

• Natural
• - Blood
• -FFP
• - Platelets
• -Human albumin
• 5, 25
• Derived from pooled
  human plasma
• Heated sterilized
  (ultrafiltration)
• Drawbacks
• Limited supply
• High cost
• Possible allergic
  reactions
• Risk of infection

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Colloids

• Synthetic (hydroxy ethyl starches)
• -Pentaspan
• -Categorized into low, medium and high
  molecular weight subgroups
• -Larger molecular weight HES seem to
  have longer
• half-lives
• -Smaller HES molecules exert a greater
  oncotic
• pressure

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Rate of fluids

• Be liberal and aggressive with fluid
  resuscitation, giving 20 ml/kg initially and
  repeating as needed. For septic shock, more than
  40ml/kg in the first hour has been shown to
  improve outcome. When approaching 80 ml/kg,
  consider the use of an inotropic agent such as
  dopamine or epinephrine. Central venous pressure
  monitoring will help fluid management in critical
  patients

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Drugs

• 1)inotropics, vasoconstrictors to reverse
  inappropriate vasodilation, and sometimes
  vasodilator drugs to reduce preload and afterload
  in cardiogenic etiologies
• 2) antibiotics (for septic shock
• 3) sodium bicarbonate
• 4) calcium
• 5) immunotherapies

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• Alpha Arteriolar constriction
• Beta-1 Increased myocardial contractility
  (inotropy) Increased heart rate (chronotropy)
• Beta-2 Peripheral vasodilation Bronchial
  smooth muscle relaxation
• Dopaminergic Smooth muscle relaxation Increase
  renal blood flow

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Examples of classic agonists include

• phenylephrine (pure alpha),
• isoproterenol (pure beta, both beta-1 and
  beta-2)
• dobutamine (selective beta-1),
• albuterol (selective beta-2),
• epinephrine (both alpha and beta).

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• Three commonly used inotropic drugs include
  dopamine, dobutamine and epinephrine.

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Dopamine

• . Low dose (1-2 mcg/kg/min) results in
  vasodilation of the splanchnic (renal) and
  cerebral vascular beds.
• Mid-dose (3-10 mcg/kg/min) has primarily a beta
  effect (chronotropic and inotropic),
• high dose (gt 10 mcg/kg/min) has a pure alpha
  effect (pressor).

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Dobutamine

• Dobutamine has a pure beta-1 (chronotropic and
  inotropic) effect, the effective dose used
  ranging from 2-20 mcg/kg/min or greater.

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Epinephrine

• Epinephrine at an infusion dose of 0.05-2
  mcg/kg/min has both beta and alpha effects, and
  may cause severe peripheral vasoconstriction or
  arrhythmias.

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vasodilator drugs

• Examples of vasodilator drugs used for "afterload
  reduction" in a failing heart to ease the work of
  "pumping" are nitrates such as nitroprusside and
  nitroglycerine.

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sodium bicarbonate

• Consider the use of sodium bicarbonate after
  assuring adequate volume resuscitation and
  ventilation, at a dose of 1-2 mEq/kg.

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Calcium

• Hypocalcemia can occur after tissue hypoperfusion
  of any etiology and can result in myocardial
  depression and hypotension. If hypocalcemia is
  documented in a symptomatic patient not
  responding to inotropes and pressors, then
  consider treating the hypocalcemia.

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Antibiotics

• Antibiotics are used for septic shock (or
  presumed septic shock). For ages less than 6
  weeks, a combination of ampicillin plus
  cefotaxime can be used. For ages greater than 6
  weeks cefotaxime or ceftriaxone can be used.

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Immunotherapies

• Immunotherapies include the use of anti-endotoxin
  (HA-1A or E5), anti-tumor necrosis factor (TNFa)
  and interleukin-1 (IL-1) receptor antagonist.

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Summary

• shock is a clinical syndrome NOT defined by
  blood pressure alone.
• Worldwide, hypovolemic shock from diarrhea
  represents a leading cause of death.
• Normal circulatory function depends on three
  factors cardiac function (the pump), vascular
  tone (the pipes), and blood volume (the fuel).

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• A disturbance in one or more, resulting in
  inadequate delivery of oxygen and nutrients to
  the tissues, leads to shock.
• Shock is a progressive, dynamic process where
  early recognition and immediate management
  (initially in the form of IV fluids) is essential
  to prevent deterioration into decompensated and
  finally irreversible shock.

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ANY QUESTIONS??
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Prioritize the initial management of the child
with shock

• . a. Administer oxygen
• b. Administer volume resuscitation
• c. Support a patent airway
• d. Support blood pressure and perfusion with
  cardioactive drugs
• e. Administer antibiotics
• f. Address oxygen carrying capacity with
  administration of blood if anemia is present

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• The most sensitive indicator of intravascular
  volume in the pediatric patient is . . . . . a.
  Cardiac output . . . . . b. Preload . . . . .
  c. Heart rate . . . . . d. Stroke volume

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In the trauma patient with compensated shock, who
is otherwise stable, blood should be considered
as part of volume resuscitation

• a. Immediately after the airway is
  secured and intravenous access
• b. After 20 cc/kg of isotonic fluid has
  been administered without clinical response
• c. after 40 cc/kg of isotonic fluid has
  been administered without clinical response d.
  After 60 cc/kg of isotonic fluid has been
  administered without clinical response e.
  After isotonic fluid administration has resulted
  in inadequate clinical response and the patient
  requires operative repair

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Which circulatory finding is the hallmark of the
diagnosis of late (decompensated) shock?

• . . . . . a. Capillary refill of 4 seconds . . .
  . . b. Altered mental status . . . . . c.
  Depressed anterior fontanelle . . . . . d.
  Hypotension . . . . . e. Absent distal pulses

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An alert, 6 month old male has a history of
vomiting and diarrhea. He appears pale and has an
RR of 45 breaths per minute, HR of 180 beats per
minute, and a systolic blood pressure of 85 mm
Hg. His extremities are cool and mottled with a
capillary refill time of 4 seconds. What would
best describe his circulatory status?

• . . . . . a. Normal circulatory status . . . .
  . b. Early (compensated) shock caused by
  hypovolemia . . . . . c. Early
  (compensated)shock caused by supraventricular
  tachycardia . . . . . d. Late (decompensated)
  shock caused by hypovolemia . . . . . e. Late
  (decompensated) shock caused by supraventricular
  tachycardia

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Appropriate initial management for the child
described in question 6 would include which of
the following?

• . . . . a. Initiation of oral rehydration
  therapy . . . . . b. Placement of an
  intraosseous line, fluid bolus of 20 ml/kg of
  normal saline . . . . . c. Placement of an
  intravenous (IV) line, fluid bolus of 20 ml/kg of
  normal saline . . . . . d. Placement of an IV
  line, adenosine 0.1 mg/kg IV

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A 2 month old infant is brought to the ED with a
pulse of 180 and BP 50/35 mm Hg. A liver edge is
palpable to the umbilicus. Skin is mottled,
capillary refill is 6 seconds with weak distal
pulses. Chest x-ray reveals cardiomegaly. During
the administration of 20 ml/kg of Ringer's
lactate, respirations become labored and rales
are heard. The next step would be

• . . . . . a. Sodium bicarbonate 1 mEq/kg IV . .
  . . . b. Repeat fluid bolus 20 ml/kg . . . . .
  c. Dopamine 5 to 10 mcg/kg/min IV infusion . . .
  . . d. Synchronous cardioversion 0.5 joule/kg .
  . . . . e. Epinephrine 0.01 mg/kg of the 110,000
  solution IV

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Thank you