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Pediatric ShockRecognition Classification andInitial ManagementCritical Concepts Course Introduction. Shock is a syndrome that results frominadequate oxygen delivery to meetmetabolic demands Oxygen delivery DO2 is less thanOxygen Consumption VO2 . Untreated this leads to metabolicacidosis organ dysfunction and death Oxygen Delivery Oxygen delivery Cardiac Output x ArterialOxygen 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 Figure 1 FACTORS AFFECTING OXYGEN DELIVERYA a gradientAcid Base Balance.Influenced By BlockersOxygenation CompetitorsTemperatureInfluenced By Conduction SystemEDV Venous Volume.Venous ToneMetabolic MilieuSV Ventricular IonsCompliance Acid BaseTemperature.Influenced ByESV Contractility ToxinsAfterload BlockersInfluenced By Temperature CompetitorsDrugs Autonomic Tone. Stages of Shock Compensated Vital organ function maintained BPremains normal Uncompensated. Microvascular perfusion becomesmarginal Organ and cellular functiondeteriorate Hypotension develops Irreversible Clinical Presentation. Early diagnosis requires a high index of Diagnosis is made through the physicalexamination focused on tissue perfusion Abject hypotension is a late andpremorbid sign. Initial Evaluation PhysicalExam Findings of Shock Neurological Fluctuating mentalstatus sunken fontanel Skin and extremities Cool pallor .mottling cyanosis poor cap refill weakpulses poor muscle tone Cardio pulmonary Hyperpnea tachycardia Renal Scant concentrated urine. Initial Evaluation Directed History Past medical history heart disease surgeries. steroid use medical problems Brief history of present exposures 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 Carbonmonoxide Cyanide Endocrine Differential Diagnosis of. Precise etiologic classification may be Immediate treatment is essential Absolute or relative hypovolemia isusually 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 Temperature control Correct metabolic abnormalities. Depending on suspected cause Antibiotics Inotropes Mechanical Ventilation Management General. Airway If not protected or unable to be maintained Breathing Always give 100 oxygen to start Sat monitor. Circulation Establish IV access rapidly CR monitor and frequent BP Management General Laboratory studies . Blood sugar Electrolytes PT PTT Type and cross Cultures. Management Volume Optimize preload Normal saline NS or lactated ringer s Except for myocardial failure use 10 20ml kg every 2 10 minutes Reasses.after every bolus At 60ml kg consider ongoing losses adrenal insufficiency intestinalischemia obstructive shock Get CXR May need inotropes . Fluid in early septic shockCarcillo et al JAMA 1991 Retrospective review of 34 pediatric patients withculture septic shock from 1982 1989 Hypovolemia determined by PCWP u o and.hypotension Overall patients received 33 cc kg at 1 hour and 95cc 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 Fluid in early septic shockCarcillo et al JAMA 1991.Group Group Group n 14 n 11 n 9 Hypovolemic 6 2 0at 6 hours Deaths 6 2 0.hypovolemicat 6 hours 2 5 1Total deaths 8 7 1 Inotropes andVasopressors. Lack of history of fluid losses history ofheart disease hepatomegaly rales cardiomegaly and failure to improveperfusion with adequate oxygenation ventilation heart rate and volume.expansion suggests a cardiogenic ordistributive component Consider Appropriate inotropic orvasopressor support Hypovolemic Shock. Most common form of shock world wide Results in decreased circulating bloodvolume decrease in preload decreasedstroke volume and resultant decrease incardiac output . Etiology Hemorrhage renal and or GIfluid losses capillary leak syndromes Hypovolemic Shock Clinically history of vomiting diarrhea ortrauma blood loss. Signs of dehydration dry mucousmembranes absent tears decreasedskin turgor Hypotension tachycardia without signsof congestive heart failure. Hemorrhagic Shock Most common cause of shock in theUnited 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 Hypotension tachycardia and pallor Hypovolemic .Hemorrhagic Shock Always begin with ABCs Replace circulating blood volumerapidly start with crystalloid Blood products as soon as available for.hemorrhagic shock Type and Crosswith first blood draw Replace ongoing fluid blood losses treat the underlying cause Septic Shock.SIRS Sepsis Septic shockMediator release exogenous endogenousMaldistribution Cardiac Imbalance of Alterations inof blood flow dysfunction metabolism.supply and Septic Shock Warm Early compensated hyperdynamic state Clinical signs Warm extremities with bounding pulses .tachycardia tachypnea confusion Physiologic parameters widened pulse pressure increased cardiacouptut and mixed venous saturation decreasedsystemic vascular resistance . Biochemical evidence Hypocarbia elevated lactate hyperglycemia Septic Shock Cold Late uncompensated stage with drop incardiac output . Clinical signs Cyanosis cold and clammy skin rapid threadypulses 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 . Septic Shock Cold Shock rapidly progresses to mutiorgansystem 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 Therapy ABCs fluid Appropriate antibiotics treatment of underlying Cardiogenic Shock Etiology . Dysrhythmias Infection myocarditis Metabolic Obstructive Drug intoxication. Congenital heart disease Trauma Cardiogenic Shock Differentiation from other types of History. Enlarged liver Gallop rhythm Murmur 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 toneleading to peripheral pooling of blood with arelative hypovolemia . Etiology Anaphylaxis Drug toxicity Neurologic injury Early sepsis. Management Treat underlying cause Obstructive Shock Mechanical obstruction to ventricular Etiology Congenital heart disease .massive pulmonary embolism tensionpneumothorax cardiac tamponade Inadequate C O in the face of adequatepreload and contractility Treat underlying cause . Dissociative Shock Inability of Hemoglobin molecule to give upthe oxygen to tissues Etiology Carbon Monoxide poisoning methemoglobinemia dyshemoglobinemias. Tissue perfusion is adequate but oxygenrelease to tissue is abnormal Early recognition and treatment of thecause is main therapy Hemodynamic Variables.in Different Shock StatesCO SVR MAP Wedg CVPHypovolemi Or e Cardiogeni Or .Obstructive Or Distributiv Or Or Or Septic Or Septic or Recognition and.Classification Initial Management of Final Thoughts Recognize compensated shock quickly have ahigh index of suspicion remember tachycardia is.an early sign Hypotension is late and ominous Gain access quickly if necessary use anintraoseous line Fluid fluid fluid Administer adequate amounts offluid rapidly Remember ongoing losses . Correct electrolytes and glucose problems quickly If the patient is not responding the way you thinkhe should broaden your differential think aboutdifferent types of shock References Recommended.Reading andAcknowledgments Uptodate Initial Management ofShock in Pediatric patients Nelson s Textbook of Pediatrics. Some slides based on works by Dr Lou DeNicola and Dr Linda Siegel for American Heart Association PALSguidelines.Pediatric Shock Recognition, Classification and Initial Management Critical Concepts Course 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.