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PEDIATRIC SHOCK

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PEDIATRIC SHOCK 2012 PALS ALGORITHM IF NOT FLUID RESPONSIVE Normotensive-Start Dopamine Hypotensive vasodilated(warm shock)-Norepinephrine Hypotensive vasoconstricted ... – PowerPoint PPT presentation

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Title: PEDIATRIC SHOCK


1
PEDIATRIC SHOCK
  • 2012

2
SHOCK
  • Shock is a syndrome that results from inadequate
    oxygen delivery to meet metabolic demands
  • Sequelae of shock are metabolic acidosis, organ
    dysfunction and death

3
SHOCK-OXGEN SUPPLY FAILS TO MEET OXYGEN DEMAND
OXYGEN SUPPLY
OXYGEN DEMAND
4
OYGEN DELIVERY
CARDIAC OUTPUT X ARTERIAL OXYGEN CONTENT
Cardiac Output
Arterial oxygen content
Hemoglobin Oxygen Saturation Partial pressure of
oxygen dissolved in plasma
Stroke Volume
Heart rate
Preload After load Contractility
5
Oxygen Delivery
  • Oxygen deliveryCO X Arterial oxygen content
  • COHeart rate X Stroke volume
  • Stroke volume depends on preload, afterload and
    contractility
  • Art Oxygen content Hb x Sa02 x 1.34 (0.003 x
    Pa02)

6
Factors affecting Oxygen delivery
  • Oxygenation-A-a gradient, DPG, acid base balance,
    Temp, Blockers
  • Stroke volume-Ventricular compliance, CVP, venous
    tone, autonomic tone, metabolic milieu,
    afterload, conduction system

7
Types of Shock
  • Hypovolemic- Hemorrhage, serum or plasma loss
  • Distributive-Anaphylactic, Neurogenic, septic
  • Cardiogenic- Myocardial, dysrrythmia, CHD(duct
    dependant)
  • Obstructive-Pneumo, tamponade, dissection
  • Dissociative-Heat, CO, cyanide, endocrine
  • RJ has Hypovolemic shock secondary to Hemorrhage

8
Case 1
  • 9 year old girl RJ with a history of variceal
    bleed presents with new onset bleed.
    O/E-responsive, HR-135, RR-38, BP-88/60,
    Sats-92. I stat-7.08/24/80/12/-4. Hb-4.2
  • What type of shock is this?
  • Hypovolemic Shock
  • What is the very first thing you would like to do
    for this patient?
  • Oxygen
  • Is this compensated or uncompensated shock- how
    does the body compensate?
  • Compensated

9
Stages of Shock
  • Compensated- Vital organ function maintained,
    normal BP
  • Uncompensated-Marginal microvascular
    perfusion.Organ and cellular function
    deteriorate. Hypotension develops.
  • Irreversible
  • RJ has compensated shock because her blood
    pressure is normal

10
Compensatory Mechanisms
  • Baroreceptors-In aortic arch and carotid sinus,
    low MAP cause vasoconstriction, increases BP, CO
    and HR
  • Chemoreceptors- Respond to cellular acidosis,
    results in vasoconstriction and respiratory
    stimulation

11
Compensatory Mechanisms
  • Renin Angiotensin- Decreased renal perfusion
    leads to angiotensin causing vasoconstriction and
    aldosterone causing salt and water retentions
  • Humoral Responses-Catecholamines
  • Autotransfusion-Reabsorption of interstitial fluid

12
RJs Clinical presentation
  • Diagnosis is based on exam focused on tissue
    perfusion
  • Neurological-Fluctuating mental status
  • Skin and extremities-Cool, pallor, mottling,
    cyanosis, poor cap refill, weak pulses, weak
    muscle tone
  • Cardio-pulmonary-Hyperpnea, tachycardia
  • Renal-Scant, concentrated urine
  • Abject hypotension is a late and premorbid sign(
    and is the flag for uncompensated shock)

13
Hypovolemic shock
  • Commonest cause worldwide
  • Decreased blood volume, decreased preload,
    decreased stroke volume
  • Signs of dehydration-tears, mucous membranes,
    skin tugor
  • Site of fluid loss may be obvious or
    concealed(liver, spleen, intracranial, GI)

14
Oxygen-What a difference!
  • Art Oxygen content Hb x Sa02 x 1.34 (0.003 x
    Pa02)
  • Pa02 on 100 is approx 650
  • Pa02 on room air is approx 100
  • If your Hb is 15 this difference in PaO2 does
    not make much difference- if your Hb is 5 it
    makes all the difference!

15
RJs Management
  • Increase oxygen delivery, decrease oxygen demand
  • Oxygen
  • Fluid
  • Blood
  • Temperature control
  • Correct metabolic abnormalities
  • Inotrope if needed

16
Labs
  • ABG
  • Blood sugar
  • Electrolytes
  • CBC
  • PT/PTT/Fibrinogen
  • Type and Cross
  • Cultures
  • Imaging

17
Volume expansion
  • Optimize RJs preload with NS or RL
  • 10-20cc/kg q 2-10min. RJ is given 2 boluses.
  • RJ is given 2 units of blood. Her heart rate
    stabilizes at 86. BP-112/80.
  • RJ is deemed stable and gets sclerotherapy

18
RJ At Endoscopy
19
Case 2
  • TN is a 5 year old girl with a history of URI
    symptoms 2 weeks ago presents with decreased
    effort tolerance, tachypnea . O/E-HR-192, RR-70,
    BP-45 systolic. Hepatomegaly, b/l rales, no heart
    murmur on exam but a gallop is heard.
  • What type of shock is this?
  • Uncompensated cardiogenic shock
  • What is the diagnosis? How do you manage this
    patient?
  • Myocarditis

20
Differentiating Cardiogenic Shock
  • History
  • PE-enlarged liver, gallop, murmur, rales
  • Chest X ray-Enlarged heart, pulmonary venous
    congestion

21
Myocarditis
22
OYGEN DELIVERY
CARDIAC OUTPUT X ARTERIAL OXYGEN CONTENT
Cardiac Output
Arterial oxygen content
Hemoglobin Oxygen Saturation Partial pressure of
oxygen dissolved in plasma
Stroke Volume
Heart rate
Preload After load Contractility
23
Managing TN
  • Increasing Oxygen supply-
  • Supplemental Oxygen
  • Improving myocardial output-altering preload,
    after load and contractility
  • Correct Anemia-Blood
  • Decreasing oxygen demand-
  • Control temperature
  • Sedation
  • Reduce myocardial work and thus oxygen consumption

24
Fluids in Cardiogenic Shock
  • Give small volume boluses of 5-10ml/kg
  • TN has myocarditis and because of this she has
    diastolic dysfunction- giving her extra fluid may
    overload her heart.

25
Ionotropes/Cardiotonics
  • Dopamine-Low dose increases renal and splanchnic
    blood flow, high dose increases HR and SVR.
  • Dobutamine- Increases contractility, may reduce
    SVR, PVR.
  • Milrinone-Inotropy and venodilation. Improve
    contractility and decrease after load

26
Ionotropes/ Cardiotonics
  • Epinephrine- Increases HR,SVR and contractility.
    End point-adequate BP, acceptable tachycardia
  • Norepinephrine-0.05-1.0mcg/kg/min. Increases SVR.
  • Be hesitant to use either of these drugs for TN
    as they increase myocardial oxygen consumption

27
TNs Hospital Course
  • 10ml/kg bolus with normal saline results in
    minimal elevation of blood pressure
  • Started on Dopamine of 5mcg/kg/min and Milrinone
    0.5 mcg/kg/min
  • Stable for transport to Cardiac ICU
  • Attempted intubation results in circulatory
    collapse-TN goes up on ECMO

28
Other causes of Cardiogenic Shock
  • Dysrhythmia
  • Infection
  • Metabolic
  • Obstructive
  • Drugs
  • Congenital heart disease
  • Trauma

29
Case 3
  • 4 year old boy RS presents with 3 day h/o fever,
    malaise. He has a past history of nephrotic
    syndrome.O/E-Minimally responsive,skin appears
    flushed and warm, and he has bounding pulses.
    HR-170 RR-30 BP-40 systolic, sats-88.
  • What type of shock does the patient have
  • Uncompensated distributive shock- Warm septic
    shock
  • What medications could be used in the management
    of this patient?
  • Fluid, antibiotics, pressors, steroids

30
Septic Shock
  • Mediator release- both exogenous and endogenous
    lead to misdistribution of blood, imbalance of
    oxygen supply and demand, alterations in
    metabolism and cardiac dysfunction

31
Warm Shock
  • Early compensated hyperdynamic state of septic
    shock
  • Warm extremities, bounding pulses, tachycardia,
    wide pulse pressure, decreased systemic vascular
    resistance and increased cardiac output
  • Often with hyperglycemia

32
Cold Shock
  • Late uncompensated stage of septic shock with
    drop in cardiac output and increased SVR
  • Cold and clammy skin, rapid thready pulses,
    shallow breathing
  • Associated metabolic acidosis, hypoxia,
    coagulopathy, hypoglycemia, capillary leak

33
PALS ALGORITHM
  • 1ST hour-20ml/kg/boluses.
  • Correct hypoglycemia and hypocalcemia.
  • Administer 1st dose of antibiotics
  • Consider vasopressor drip and stress dose
    hydrocortisone
  • DETERMINE WHETHER FLUID RESPONSIVE

34
PALS ALGORITHM
  • IF NOT FLUID RESPONSIVE
  • Normotensive-Start Dopamine
  • Hypotensive vasodilated(warm shock)-Norepinephrine
  • Hypotensive vasoconstricted(cold
    shock)-Epinephrine
  • EVALUATE MIXED VENOUS SAT, GOALgt70

35
RS- Hospital Course
  • 100ml/kg of fluid is given, BP improves to 60/30
  • Started on Norepinephrine drip following which
    BP improves to systolic of 80.
  • Rt IJ placed ScVO2-74
  • Hydrocortisone 2mg/kg-1 dose given
  • Starts Vancomycin and Ceftriaxone
  • Microbiology calls to tell you there are Gram Neg
    rods on blood culture smear

36
PALS ALGORITHM
  • ScvO2gt70, Low BP, warm shock-Additional fluid.
    Norepinephrine /- Vasopressin
  • ScvO2lt70, normal BP, poor perfusion-Transfuse to
    Hbgt10g/dl. Consider milrinone/ nitroprusside/dobut
    amine
  • ScvO2lt70, low BP, poor perfusion-Transfuse to
    Hbgt10g/dl. Consider epinephrine or dobutamine
    norepinephrine
  • ADRENAL INSUFFICIENCY-
  • Hydrocrtisone 2mg/kg

37
How much fluid is to much?
  • Fluids in early septic shock- Carcillo, JAMA 1991
  • Three treatment groups
  • 1-20cc/kg in first hour
  • 2- Upto 40cc/kg in first hour
  • 3- More than 40cc/kg in first hour
  • NO DIFFERENCE IN ARDS BETWEEN GROUPS

38
Conclusions
  • Recognise shock quickly-tachycardia is the first
    sign, hypotension is late
  • Gain access quickly-if needed use IO. PIV better
    than a central line
  • If patient is not responding the way you think
    broaden your differential, think about other
    types of shock.
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