Professional Documents
Culture Documents
Shock States in Children
Shock States in Children
Hgb
CaO2
A-a gradient
DPG
Acid-Base Balance
Influenced By Blockers
Oxygenation Competitors
Temperature
DO2
Drugs
Influenced By Conduction System
HR
CVP
CO
EDV Venous Volume
Venous Tone
Metabolic Milieu
SV Ventricular Ions
Compliance Acid Base
Temperature
Influenced By
Drugs
ESV Contractility Toxins
Afterload Blockers
Influenced By Temperature Competitors
Drugs Autonomic Tone
Stages of Shock
Compensated
– Vital organ function maintained, BP
remains normal.
Uncompensated
– Microvascular perfusion becomes
marginal. Organ and cellular function
deteriorate. Hypotension develops.
Irreversible
Clinical Presentation
Early diagnosis requires a high index of
suspicion
– surgeries
– steroid use
– medical problems
– onset
Differential Diagnosis of Shock
Cardiogenic
Hypovolemic Myocardial dysfunction
Hemorrhage Dysrrhythmia
Fluid loss Congenital heart
Drugs disease
Distributive Obstructive
Analphylactic Pneumothorax,
Neurogenic CardiacTamponade,
Aortic Dissection
Septic
Dissociative
Heat, Carbon
monoxide, Cyanide
Endocrine
Differential Diagnosis of Shock
Precise etiologic classification may be
delayed
Immediate treatment is essential
Absolute or relative hypovolemia is
usually present
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
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
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
Management-General
Laboratory studies:
– ABG
– Blood sugar
– Electrolytes
– CBC
– PT/PTT
– Type and cross
– Cultures
Management-Volume Expansion
Optimize preload
Normal saline (NS) or lactated ringer’s
(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.
Fluid in early septic shock
Carcillo, et al, JAMA, 1991
Mediator release:
exogenous & endogenous
Etiology:
– Dysrhythmias
– Infection (myocarditis)
– Metabolic
– Obstructive
– Drug intoxication
– Congenital heart disease
– Trauma
Cardiogenic Shock
Differentiation from other types of
shock:
– History
– Exam:
Enlarged liver
Gallop rhythm
Murmur
Rales
– CXR:
Enlarged heart, pulmonary venous congestion
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
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
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.
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
Hemodynamic Variables in
Different Shock States
CO SVR MAP Wedge CVP
Hypovolemic Or
Cardiogenic Or
Obstructive Or
Distributive Or Or Or
Septic: Early Or
Septic: Late or
Recognition and Classification
Initial Management of Shock
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.
References, Recommended
Reading, and Acknowledgments
Uptodate: Initial Management of
Shock in Pediatric patients
Nelson’s Textbook of Pediatrics
Some slides based on works by Dr.
Lou DeNicola and Dr. Linda Siegel for
PedsCCM
American Heart Association PALS
guidelines