DEPARTMENT OF PEDIATRICS AND CHILD

HEALTH

APPROACH TO CHILD WITH SHOCK

Moderator : Dr.YOSEPH BACHA (R2)

Presentor: Dr.DEJENE HUMNA (MI)
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 Out-lines

• Introduction
• Types of shock
• Diagnosis of shock
• Management of shock
• Shock in malnourished children
• Refractory shock

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 INTRODUCTIOPN

• Shock is an acute syndrome characterized by the

body's inability to deliver adequate oxygen to meet
the metabolic demands of vital organs and tissues.

• Occurs in approximately 2% of all hospitalized

infants, children, and adults in developed countries,

• Most patients die as a result of associated

complications and multiple organ dysfunction
syndrome (MODS).
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 TYPES OF SHOCK

 Shock classification systems generally define 5

major types of shock
1. Hypovolemic shock
2. Cardiogenic shock
3. Distributive shock
4. Obstructive shock
5. Septic shock

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 TYPES OF SHOCK….

Hypovolemic shock
 The most common cause of shock in children
worldwide
 Potential etiologies
• Blood loss: hemorrhage
• Plasma loss: burns, Nephrotic syndrome
• Water/electrolyte loss: vomiting, diarrhea

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 TYPES OF SHOCK….

Cardiogenic shock
• Cardiac pump failure secondary to poor myocardial
function
• Potential etiologies
– Congenital heart disease
– Cardiomyopathies: infectious or acquired, dilated
or restrictive
– Ischemia
– Arrhythmias

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 TYPES OF SHOCK….

Distributive shock
 Abnormalities of vasomotor tone from loss of venous
and arterial capacitance
 Can lead to functional hypovolemia with decreased
preload .
 Etiologies
 Anaphylaxis
 Neurogenic: loss of sympathetic vascular tone
secondary to spinalcord or brainstem injury
 drugs
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 TYPES OF SHOCK….

Obstructive shock
• Lesion that creates a mechanical barrier that impedes
adequate cardiac output
• Decreased venous return
• includes
– Pericardial tamponade
– Tension pneumothorax
– Pulmonary embolism and
– ductus-dependent congenital heart lesions
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 TYPES OF SHOCK….

Septic shock
• Usually involves a more complex interaction of
distributive, hypovolemic, and cardiogenic shock.
• Causes are
• Bacterial
• Viral
• Fungal

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 Diagnosis

• History

• Physical Examination

• Investigations

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 diagnosis…..
History
• A history of fluid loss
• trauma history
• Fever and/or immunocompromise
• HX of chronic heart disease
• Hx of chronic steroid therapy,
• Hx of exposure to an allergen
• Hx of decreased urine output

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 Physical Examination

• Change in mentations
• Children with shock are usually tachypnea.
• Tachycardia is a consistent sign of shock
• Prolonged capillary refill
• Absent distal pulses, cool extremities
• Abdominal distention, mass, or tenderness
• Children with shock may have normal BP
• Temperature – Fever (or hypothermia in young
infants) is often consistent with septic shock.
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 Investigations

• CBC, Blood group and cross match

• RBS
• Serum electrolytes
• Urine analysis
• S/E
• RFT
• Serum lactic acid level
• Coagulation profile

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 Management of shock

• Early recognition
• Stabilization of airway,
• breathing, and
• circulation

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 Management of shock….

• Depending on the severity of shock, further airway

intervention, including:
-intubation and
-mechanical ventilation,
• Immediately following establishment of intravenous
(IV) or intraosseous access, therapy should be
initiated

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 1.Management hypovolemic shock

• Aggressive fluid resuscitation and control of ongoing

losses
• Subsequent repletion of deficits
• Correction of metabolic abnormalities

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 1.Management hypovolemic shock….

• Rapid IV administration of 20 mL/kg isotonic fluid

should be initiated
• This bolus should be repeated quickly up to 60-
80ml/kg
• Not improved after total of 60 mL/kg of isotonic
fluid Concider other causes of shock.

• Rapid improvement occurs with initial fluid

administration.

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 1.Management hypovolemic shock…

• After the initial fluid bolus:

- Strong peripheral pulses
-Skin perfusion (warm, with capillary refill <2
seconds)
-Normal mental status
-Urine output (≥1 mL/kg/hr)
-Blood pressure (systolic pressure at least fifth
percentile for age:

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 1.Management hypovolemic shock…….

• Hemorrhagic shock should receive blood

• Require definitive treatment for the cause of
hemorrhage
• PRBC should be infused in 10 mL/kg boluses.

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 1.Management hypovolemic shock…

• If shock remains refractory following 60-80 mL/kg of

volume resuscitation,
• vasopressor therapy should be instituted while
additional fluids are administered.

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 1.Management hypovolemic shock…

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 1.Management hypovolemic shock…

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 1.Management hypovolemic shock…
• Shock in severe acute malnutrition:
– considered to have shock in lethargic or unconscious
- NS or RL with 5% glucose at 15 ml/kg over 1 hr.(half-strength
Darow solution with 5% glucose).

• Pulse and breathing rate every 5-10 minutes.

• Discontinue iv infusion if either of these increase (pulse by

15,RR BY 5).

• Change IV fluid with oral intake/Resomal after 2 hrs.

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 1.Management hypovolemic shock…

• If there is improvement:repeat 15ml/kg over 1hr.

• If no improvement:give maintainance IV fluid

4ml/kg/hr while waiting for blood.

• Trasfuse fresh whole blood 10ml/kg/hrs slowly

over(use packed cells if in cardiac falure)

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 2.Management septic shock

• Early administration of broad-spectrum antimicrobial

agents

• Neonates should be treated with ampicillin plus

cefotaxime and/or gentamicin

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 2.Management septic shock ….

• Community-acquired infections with Neisseria

meningitidis treated empirically with a 3rd-generation
cephalosporin

• Haemophilus influenzae treated empirically with a

3rd-generation cephalosporin

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 2.Management septic shock ….

• Vigorous fluid resuscitation

• Begin with a bolus of 20 mL/kg of isotonic
crystalloid solution as rapidly as possible.
• Repeated up to 60-80ml/kg,and reassess
• Consider vasoactive therapy
• Corrected Hypoglycemia
• Calcium gluconate 10 percent solution in a dose of 50
to 100 mg/kg

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 3.Management Distributive shock

• Caused by a primary abnormality in vascular tone,

• Early initiation of a vasoconstrictive agent to
increase SVR
• Either phenylephrine or vasopressin and
epinephrine for anaphylaxis.
• Epinephrine improve the myocardial activities

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 4.Management Cardiogenic shock

• Decompensate quickly when fluid administered.

• Poor cardiac output with a compensatory elevation in
SVR.
• Smaller boluses (5-10 mL/kg) should be given to
replace deficits and maintain preload
• further administration of fluids should be provided
judiciously.
• Early initiation of epinephrine or dopamine

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 4.Management Cardiogenic shock….

• Poor peripheral perfusion and acidosis may persist

• Milrinone improve systolic function and decrease
SVR without causing a significant increase in heart
rate
• Enhancing diastolic relaxation
• Dobutamine or nitroprusside,

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 4.Management Cardiogenic shock….

• Improvement peripheral perfusion, urine output,

mental status and resolution of acidosis

• Norepinephrine and vasopressin, should be avoided

• Further decompensation and precipitate cardiac

arrest as a result of the increased afterload

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 5.Management Obstructive shock
• Fluid resuscitation may be briefly temporizing in
maintaining cardiac output,

• The primary insult must be immediately addressed.

• Life saving therapeutic interventions

• Pericardiocentesis,chest tube thrombectomy/thrombolysis

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 Follow up
• Electrolyte levels should be monitored closely.
• Hypoglycemia should treated
• Hypocalcemia, should be treated with a goal of
normalizing the ionized calcium concentration

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 Refractory shock

• Considered steroid unresponsive to fluid

resuscitation and catecholamines.
• Adrenal function is another important
consideration in shock, and hydrocortisone
replacement may be beneficial.

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 Refractory shock…

• Up to 50% of critically ill patients have adrenal

insufficiency.

• Patients with congenial adrenal hypoplasia, abnormalities of

the hypothalamic-pituitary
• And recent therapy with corticosteroids.

• These patients should receives tress doses of

hydrocortisone
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 PROGNOSIS

• In septic shock, mortality rates 3% in previously

healthy children

• And 6-9% in children with chronic illness (compared

with 25-30% in adults)

• Early recognition and therapy, can reduce the

mortality rate

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 REFERENCE

• DavidA.T urner ,Ira M. Cheifetz Nelson T extbook of

Pediatrics page 2706-2741
• uptodate 21.2,(markwaltman.md ,Initial evaluation of shock
in children
• ETAT Ethiopia manual for participants 2014(page-38)

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 Thank you

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