SHOCK

Emergency pediatric PICU division

Pediatric Department
Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital

Definition
Shock is an acute, complex state of
circulatory dysfunction that results in
failure to deliver sufficient amounts of
oxygen and other nutrients to meet
tissue metabolic demands

Pathophysiology
Delivery of Oxygen (DO2):
DO2 = Cardiac output (CO) x Arterial oxygen content (CaO 2)
CO = Heart Rate (HR) x Stroke Volume (SV)
CaO2= Hb x SaO2 x 1,39

CO = Cardiac Output
SVR = Systemic Vascular resistance
SV = Stroke Volume
HR = Heart Rate
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Clinical Manifestation
Three phases: compensated, uncompensated, irreversible
Clinical Sign

Compensated

Heart rate
Systolic BP
Pulse volume
Capillary refill
Skin
Respiratory rate
Mental state

Tachycardia +
Normal
Normal/reduced
Normal/increased
Cool,pale
Tachypnoea +
Mild agitation

Uncompensated
Tachycardia ++
Normal or falling
Reduced +
Increased +
Cool,mottled
Tachypnoea ++
Lethargic
Uncooperative

Irreversible
Tachycardia
/bradicardia
Plummeting
Reduced ++
Increased ++
Cold,deathly pale
Sighing respiration
React only to pain or
unresponsive

Management

Intubation & mechanical ventilation

Fluid resuscitation
Vasoactive infusion

FUNCTIONAL CLASSIFICATION

Hypovolemia
Cardiogenic
Obstructive
Distributive
Septic
Endocrine

HYPOVOLEMIC
SHOCK

A decrease in intra vascular blood volume to such an extent that

effective tissue perfusion can not be maintain
Most common cause of shock in infants & children
Etiology:
Hemorrhage
Plasma loss
Fluid & electrolyte loss
Hypovolemia preload SV CO

CLINICAL MANIFESTATION:
Tachycardia
Skin mottling
Prolonged capillary refill
Cool extremities
UOP
Hypotensive
Lethargy / comatose

THERAPY
Adequate oxygenation and ventilation
Rapid volume replacement reestablish circulation:
Crystalloid: 20 ml/kg shock persist 20 ml/kg
Hemorrhagic: transfusion

Shock (+)

Continuous monitoring of HR, arterial BP, CVP, UOP

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CVP:
< 10 mmHg fluid infusion until preload is reach
>10 mmHg indication: flow-direct thermo dilution
pulmonary artery catheter and/or echocardiogram

Ventricular filling pressure rises without evidence of improvement

in cardiovascular performance

Discontinue fluid resuscitation

Inotropic agent (+)

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REFRACTORY SHOCK:

Unrecognized pneumothorax / pericardial effusion

Intestinal ischemia
Sepsis
Myocardial dysfunction
Adrenal cortical insufficiency
Pulmonary hypertension

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CARDIOGENIC SHOCK
The pathophysiologic state in which abnormality of cardiac
function is responsible for the failure of the cardiovascular system
to meet the metabolic needs of tissue
Depressed CO
Etiology: Heart rate abnormalities, Cardiomyopathies/carditis,
Congenital heart disease, Trauma
Myocardial dysfunction is frequently a late manifestation of shock
of any etiology
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CLINICAL MANIFESTATION
Tachycardia
Hypotensive
Diaphoretic
Oliguria
Acidotic
Cool extremities
Altered mental status
Hepatomegaly
Jugular venous distension
Rales
Peripheral edema
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THERAPY
Tissue oxygen supply
Tissue oxygen requirements
Correct metabolic abnormalities
Preload should be optimized
Myocardial contractility: inotropic agent cathecholamine:
norepinephrine, epinephrine, dopamine & dobutamine

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OBSTRUCTIVE SHOCK
Caused by inability to produce adequate CO despite normal
intravascular volume & myocardial function
Causative factor:
Acute pericardial tamponade
Tension pneumothorax
Pulmonary / systemic hypertension
Congenital / acquired outflow obstruction

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CARDIAC TAMPONADE
Hemodinamically significant cardiac compression accumulation
pericardial contents that evoke & defeat compensatory mechanism
Physical examination:
Pulsus paradoxus
Narrowed pulse pressure
Pericardial rub
Jugular venous distension
Definitive treatment: removed pericardial fluid or air surgical drainage /
pericardiocentesis
Medical management:
Blood volume expansion maintain venoarterial gradients
Inotropic agent
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DISTRIBUTIVE SHOCK
Results from maldistribution of blood flow to the tissue
May be seen with anaphylaxis, spinal / epidural
anesthesia, disruption of spinal cord, inappropriate
administration vasodilatory medication
Treatment:
Reversal underlying etiology
Vigorous fluid administration
Vasopressor infusion

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SEPTIC SHOCK
Contains many elements of the other types of shock discussed
previously (hypovolemic, cardiogenic, and distributive shock)
SIRS (Systemic Inflammatory Response Syndrome): non specific
inflammatory response
Modified criteria for SIRS:

Temp. >38,5 C or < 36 C

Tachycardia
Tachypnea
WBC / or >10% immature neutrophils

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 Sepsis: SIRS + documented infection

Severe sepsis: Sepsis + end organ dysfunction
Septic shock: Sepsis with hypotension despite adequate fluid
resuscitation

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MANAGEMENT:

Early recognition
Antibiotics appropriate with microbiological examination
Initial fluid resuscitation 20 ml/kg boluses over 5-10
minutes up to 40-60 ml/kg in the first hour
Inotropic / vasopressor refractory to fluids
Mechanical ventilation refractory shock
Hydrocortisone
Glycemic control
Blood transfusion
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Recognize decreased mental status and perfusion.

Maintain airway and establish acces according to PALS guidelines

0 min
5 min

Push 20 cc/kg isotonic saline or colloid boluses up to and

Over 60 cc/kg correct hypoglycemia and hypocalcemia

15 min

Fluid refractory shock**

Fluid responsive*

Establish central venous access, begin dopamine or

Dobutamine therapy and establish arterial monitoring
Fluid refractory-dopamine/dobutamine resistant shock

Observe in PICU

Titrate epinephrine for cold shock, norepinephrine for warm shock to

Normal MAP-CVP difference for age and SVCO 2 saturation > 70%
Catecholamine-resistant shock resistant

At risk of adrenal insufficiency ?

60 min

Not at risk ?

Draw baseline cortisol level

Then give hydrocortisone

Draw baseline cortisol level or perform

ACTH stim test. Do not give hydrocortisone

Normal Blood Pressure Cold Shock

SVC O2 Sat < 70%

Low Blood Pressure Cold Shock

SVC O2 Sat < 70%

Low Blood Pressure Warm Shock

SVC O2 Sat < 70%

Add vasodilator or type III PDE

inhibitor with volume loading

Titrater volume resuscitation

and epinephrine

Titrater volume and

norepinephrine

Persistent Catecholamine-resistant shock

Start cardiac output measurement and direct fluid, inotrope, vasopressor, vasosilator,
and hormonal therapies to attain normal MAP-CBP and CI > 3.3 and < 6.0 L/min/m 2

Refractory shock

ECMO

THANK
YOU

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