Pediatric Shock

Vichram S Paulraj
Medical Student

OBJECTIVES

Definition
Physiology
Classification of Shock
Common Etiologies
Recognition and Assessment
Management

DEFINITION
An acute, complex state of circulatory
dysfunction that results in failure to deliver
sufficient amount of oxygen and nutrients to
meet tissue metabolic demands.
Therefore, basically DO2 < VO2.
If prolonged and left untreated- Can lead to
multiple organ failure and eventually death.

igure 1.

FACTORS AFFECTING OXYGEN DELIVERY

Hgb

CaO2

A-a gradient
DPG
Acid-Base Balance
Blockers
Competitors
Temperature

Influenced By

Oxygenation
DO2
Influenced By

Drugs
Conduction System

HR
CO

EDV
SV

CVP
Venous Volume
Venous Tone

Ventricular
Compliance
Influenced By

ESV

Contractility

Influenced By

Afterload
Temperature
Drugs

Metabolic Milieu
Ions
Acid Base
Temperature
Drugs
Toxins
Blockers
Competitors
Autonomic Tone

What is needed to maintain

Perfusion??
PUMP PIPES FLUID-

Heart
Vessels
Blood

How can Perfusion fail??

Pump Failure
Pipe Failure
Loss of Volume

Causes of Inadequate Perfusion

Inadequate Pump
Inadequate preload
Poor contractility
Excessive Afterload
Inadequate HR

Inadequate Fluid Volume

Hypovolemia
Inadequate Container
Excessive Dilatation
Inadequate systemic vascular resistance

PHASES OF SHOCK
Compensated Shock
- Intrinsic regulatory mechanisms
- Vital organ function is maintained

Uncompensated Shock
- Compromise of microvascular perfusion
- Deterioration of organ function
- Hypotension develops

Irreversible Shock
- Damage to key organs
.

RECOGNITION &
ASSESSMENT
Respiratory
- Quality of Respirations
- Auscultatory Findings

Cardiovascular
- Pulse
- Blood Pressure, Pulse pressure

Skin
-Color
-Capillary Refill
-Temperature
-Moist/ Dry

Recognition & Assessment..

Neurological
-Full/ flat/ sunken fontanelle
-Calm/ anxious/ irritable
-Alert/ lethargic
-Responsive to parents
-level of consciousness
-Muscle tone
-pupillary size
Renal
- Urinary output

SIGNS OF SHOCK

1.
2.
3.
4.

Early Signs
Tachycardia
Normal blood pressure
Mildly delayed capillary refill
Fussy child

Signs of Shock..

Late Signs

1.
2.
3.
4.
5.
6.
7.

Persisting tachycardia or bradycardia

Hypotension- LATE sign!!
Poor capillary refill
Altered mental status
Irregular breathing pattern
Poor muscle tone
Lower limit of SBP=70 + (2 x age in years)

FUNCTIONAL CLASSIFICATION
OF SHOCK
Distributive

Whole blood Septic

loss
Anaphylaxis

Cardiogenic

Obstructive

Infectious

Pericardial
tamponade

CMP

Plasma loss
Fluid/
electrolyte
losses

Spinal
anesthesia

Septic

Carditis
Metabolic
Arrythmia

Tension
Pneumothorax
Pulmonary
HTN

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Hypovolemic

HYPOVOLEMIC SHOCK
MCC of shock in children
Decrease in the intravascular blood volume to
such an extent that effective tissue perfusion
cannot be maintained.

Preload decrease
Decreased Stroke Volume
Decreased C.O.

Management of
Hypovolemic Shock
Establishment of adequate oxygenation and ventilation
O2- ALWAYS the first drug administered.
Adequate IV or IO
Early correction of hypovolemia
-Crystalloids: Readily available, safe, least expensive
-First bolus 20cc/kg- ASAP
-Continuous monitoring of vitals
-Monitoring of CVP: Maintain > 10mmHg
-Identify causes of ongoing losses
- Blood available: if hemorrhagic shock.

Solution makeup
Osmol Glucose

5% D/W
10%D/W
.45% NS
.9% NS
LR

278
556
154
308
274

Na+ Cl- K+ Ca+ Lactate

50g/l
0
0
100g/l
0
0
0
77
77
0
154 154
0
130 109

0
0
0
0
0
0
0
0
4
1.5

Na, Cl, K, Ca, and lactate are measured in mmol/liter.

0
0
0
0
28

The Stages of Shock

Normal Eucardia, normal BP and CR
Tachycardia alone, normal BP and CR
HR is maintaining CO despite reduced stroke volume (CO = HR x SV)
Hypotension with normal CR = Warm shock
Vascular tone cannot maintain blood pressure but

HR maintains CO

Prolonged CR with normal BP = Cold shock

HR does not maintain CO but vascular tone maintains BP
Prolonged CR + hypotension = Decompensated Cold Shock
HR does not maintain CO and vascular tone does not maintain BP

(Slides are courtesy of Dr. Carcillo) (Carcillo et al., Pediatrics 2009)

CARDIOGENIC SHOCK
1. a. Toxic substances released during
course of shock.
b. Myocardial Edema
c. Adrenergic receptor dysfunction
d. Impaired sarcolemmic Calcium flux
e. Reduced coronary blood flow
2. Diastolic Dysfunction

Pathophysiology
LV able to eject less volume of bld/ beat
Dec. Stroke Volume
Increased Venous Return
Increased EDV

Dec.C.O
Increased O2
extraction by
tissues

Increased LV diastolic filling pressure

Arterial O2
desaturation
Backflow from LV to lungs

Etiology of Cardiogenic
Shock
Dysrrhythmias
Cardiomyopathies

Congenital Heart Disease

Trauma

Hypoxic-Ischemic event
Infectious
Metabolic
Connective Tissue Disorder
NM disorders
Toxins
Others

Recognizing Cardiogenic Shock

Excessive Resp
effort
Prolonged
feeding time
Poor weight
gain
Excessive
sweating
Frequent resp.
tract infections

Physical Examination

Inc HR, Inc RR

Gallop
Cold extremites, weak
peripheral pulses
Rales
Dyspnea, cyanosis
Hepatomegaly
Neck V dsitension
Peripheral edema
Hypotension

CXR
Cardiomegaly
Pulm

venous
congestion
Hyperinflation

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History

Managing Cardiogenic Shock

Minimize Myocardial Maximize Myocardial Exclude & Explore
O2 demands
Performance
Intubation

Correct

Dysrhythmias

Exclude

traumatic or

CHD
normothermia

Optimize

Preload
Explore

Provide

sedation

Improve

Contractility

Correct

anemia

Reduce

Afterload

surgical options

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Maintain

OBSTRUCTIVE SHOCK

Normal Preload
Normal myocardial function
Inadequate C.O.
Ac. Pericardial Tamponade
Etiology
Tension Pneumothorax
Pulmonary/ Systemic HTN
Congenital/ Acquired outflow
obstructions

Recognize and treat underlying cause!!

DISTRIBUTIVE SHOCK
PathoPhysiology:
a. Maldistribution of blood flow to tissue due to abnormal
vasomotor tone.
b. Profound inadequate tissue oxygenation.
c. Normal or High C.O.

Etiology

Anaphylaxis
Spinal or Epidural anesthesia
Disruption of spinal cord
Iatrogenic

Management: Recognize and treat underlying cause

SEPTIC SHOCK
SIRS/Sepsis/Septic shock

Mediator release:
exogenous & endogenous

Cardiac

of blood flow

dysfunction

Imbalance of
oxygen
supply and
demand

Alterations in
metabolism

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Maldistribution

SEPSIS

ACUTE ORGAN
DYSFUNCTION
(Severe Sepsis)

DEATH

Sepsis

Severe Sepsis

Systemic inflammatory
response to variety of severe
clinical insults indicated by 2 or
more of the following:
Temp > 38 or < 36
HR > 90bpm (adults)/
>2SD(ped)
RR > 20/min (adults)/>2SD(ped)
OR PACO2 <32mmhg
WBC>12000, <4000 or > 10%
bands

Systemic response to
infection manifested by
2 or more of the
following as a result of
infection:
Temp > 38 or < 36
HR>90
RR>20 or PaCO2 < 32
WBC>12000. <4000 or
>10% bands

Sepsis associated
with:
Organ dysfunction
Hypoperfusion (Lactic
acidosis, oliguria,
altered mental status)
Hypotension

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SIRS

Warm Shock

Cold Shock

Fluid-Refractory/
Dopamine resistant

Catecholamine
Resistant

Refractory Shock

Early,

Late,

Persistance of shock
despite > 60cc/kg
fluid resuscitation

Persistance of shock
despite administration of
direct acting
catecholamines
Epinephrine/
Nor-Epinephrine

Persistance of shock
despite:
-Goal direct inotropic/
pressor therapy
-Use of vasodilators
-Maintenance of
metabolic and
hormonal homeostasis

Clinical

Signs

-Inc.HR
-Warm
extremities,
bounding pulses
Physiologic

Parameters
-Wide PP
-Inc. C.O.
-Inc. MvO2
-Dec.SVR
Lab

Data
-Hypocardia
-Inc. Lactate
-Inc.Glucose

Uncompensated
Clinical Signs
-Cold, clammy extremities
-Rapid, thready pulses
-Shallow breathing
Physiologic

Parameters

-Narrow PP
-Dec.CVP, C.O
-Dec. MvO2 sat
-Inc. SVR
-Oliguria
-Capillary Leak
Data
-Metab. Acidosis
-Hypoxia
-Coagulopathy
-Hypoglycemia

Persistance of shock
despite Dopamine at
>10mcg/kg/mn

Lab

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compensated

Antibiotic Guidelines in Sepsis by Suspected Site

Community-Acquired Sepsis

Pneumonia-Quinolone PLUS B-lactam

Abdominal-Carbapenem OR Pip-Tazo
Skin/Soft Tissue-Vanco PLUS Carbapenem or Pip-Tazo
Urinary Tract-Quinolone PLUS Amp/Vanco
Unknown-Vanco PLUS B-lactam

Health-Care Associated Sepsis

Lung-B-lactam PLUS Vanco

Bloodstream
-B-lactam PLUS Vanco +/- Antifungal
Surgical Site
-B-lactam PLUS Vanco +/- Anaerobic coverage
Suspected Candida-Caspofungin
Unknown-B-lactam PLUS Vanco

Therefore, the Basics.

Stabilize respiration
Assess perfusion
Fluid administration
IV Access
Vasopressors
Inotropic therapy
Red blood cell transfusions if needed

References

Pediatric Critical Care: Fuhrman, Zimmerman

Surviving Sepsis Guidelines
E-medicine
Uptodate online
SCCM website