2. Stages of Shock
Compensated
– Vital organ function maintained, BP
remains normal.
Uncompensated
– Microvascular perfusion becomes
marginal. Organ and cellular function
deteriorate. Hypotension develops.
Irreversible
4. Hypovolemic Shock
Most common form of shock world-
wide
Results in decreased circulating blood
volume, decrease in preload, decreased
stroke volume and resultant decrease in
cardiac output.
Etiology: Hemorrhage, renal and/or GI
fluid losses, capillary leak syndromes
5. Hypovolemic Shock
Clinically, history of vomiting/diarrhea
or trauma/blood loss
Signs of dehydration: dry mucous
membranes, absent tears, decreased
skin turgor
Hypotension, tachycardia without signs
of congestive heart failure
6. Hemorrhagic Shock
Most common cause of shock in the
United 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
fracture)
Hypotension, tachycardia and pallor
7. Hypovolemic/Hemorrhagic
Shock: Therapy
Always begin with ABCs
Replace circulating blood volume
rapidly: start with crystalloid
Blood products as soon as available for
hemorrhagic shock (Type and Cross
with first blood draw)
Replace ongoing fluid/blood losses &
treat the underlying cause
9. Cardiogenic Shock
Differentiation from other types of
shock:
– History
– Exam:
Enlarged liver
Gallop rhythm
Murmur
Rales
– CXR:
Enlarged heart, pulmonary venous congestion
10. 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
11. Inotropic support in cardiogenic shock:
If normotensive: dobutamine (5-20
mic/kg/min), milrinone (0.25-1 mic/kg/min)
or levosimendan(0.05-0.2 mic/kg/min)
If hypotensive: low dose adrenaline (0.05-0.3
mic/kg/min) then add one of the inodilators
mentioned above
DON‘T FORGET: any fluid bolus in cases of
cardiogenic shock should not exceed 5 cc/kg to
avoid overoad.
12. Obstructive Shock
Mechanical obstruction to ventricular
outflow
Etiology: Congenital heart disease,
massive pulmonary embolism, tension
pneumothorax, cardiac tamponade
Inadequate C.O. in the face of adequate
preload and contractility
Treat underlying cause.
13. Distributive Shock
Due to an abnormality in vascular tone
leading to peripheral pooling of blood with a
relative hypovolemia.
Etiology
– Anaphylaxis
– Drug toxicity
– Neurologic injury
– Early sepsis
Management
– Fluid
– Treat underlying cause
14. Dissociative Shock
Inability of Hemoglobin molecule to give up
the oxygen to tissues
Etiology:
• Carbon Monoxide poisoning,
methemoglobinemia, dyshemoglobinemias
Tissue perfusion is adequate, but oxygen
release to tissue is abnormal
Early recognition and treatment of the cause
is main therapy
18. Cold Shock rapidly progresses to mutiorgan
system 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
prognosis
Therapy: ABCs, fluid
Appropriate antibiotics, treatment of underlying
cause
20. Initial therapeutic end points of resuscitation
of septic shock:
1. Capillary refill time of ≤2 seconds.
2. Normal blood pressure for age.
3. Normal pulses with no differential between peripheral
and central pulses.
4. Warm extremities.
5. Urine output >1 mL/kg/hr.
6. Normal mental status.
7. Scvo2 saturation ≥70%.
8. Cardiac index between 3.3 and 6.0 L/min/m2 should
be targeted thereafter (grade 2C)
21. B. Antibiotics and Source Control:
All children with septic shock should receive coverage
for methicillin-resistant Staphylococcus aureus
(MRSA).
Coverage for enteric organisms should be added
whenever clinical features suggest genitourinary (GU)
and/or gastrointestinal (GI) sources.
Treatment for Pseudomonas species should be
included for children who are immunosuppressed or at
risk for infection with these organisms (ie, those with
cystic fibrosis).
22. Listeria monocytogenes and herpes simplex virus are
important pathogens in neonates≤ 28 days of age.
When treating empirically, antibiotics which can be
given by rapid intravenous bolus (eg, beta-lactam
agents or cephalosporins) should be administered first
followed by infusions of antibiotics, such as
vancomycin, that must be delivered more slowly.
Ongoing antimicrobial therapy should be modified
based upon culture results, including antimicrobial
susceptibility and the patient's clinical course.
23. C. Fluid Resuscitation:
isotonic crystalloids or albumin with boluses of
up to 20 mL/kg crystalloids (or albumin
equivalent) over 5–10 minutes, titrated to
reversing hypotension, increasing urine output,
and attaining normal capillary refill, peripheral
pulses, and level of consciousness without
inducing hepatomegaly or rales.
24. If hepatomegaly or rales exist then inotropic
support should be implemented, not fluid
resuscitation. In non-hypotensive children with
severe hemolytic anemia (severe malaria or
sickle cell crises) blood transfusion is
considered superior to crystalloid or albumin
bolusing.
25. D. Inotropes/Vasopressors/Vasodilators:
Children with severe sepsis can present with
low cardiac output and high systemic vascular
resistance (cold septic shock), high cardiac
output and low systemic vascular resistance
(warm septic shock), or low cardiac output
and low systemic vascular resistance shock.
26. A child may move from one hemodynamic
state to another, Vasopressor or inotrope
therapy should be used according to the
hemodynamic state.
Dopamine refractory shock may reverse with
epinephrine if cold or norepinephrine infusion
if warm.
27. In the case of extremely low systemic vascular
resistance despite the use of norepinephrine,
the use of vasopressin and terlipressin has been
described in a number of case reports, yet
evidence to support this in pediatric sepsis, as
well as safety data, are still lacking.
When vasopressors are used for refractory
hypotension, the addition of inotropes is
commonly needed to maintain adequate
cardiac output.
28. E. Corticosteroids:
Timely hydrocortisone therapy in children with
fluid refractory, catecholamine resistant shock
and suspected or proven absolute (classic)
adrenal insufficiency.
29. F. Blood Products and Plasma Therapies:
In cases of low superior vena cava oxygen
saturation (< 70%), maintain hemoglobin
levels of 10 g/dL.
After stabilization and recovery from shock
and hypoxemia then a lower target > 7.0
g/dL can be considered reasonable.
30. Administer platelet prophylactically when counts
are <10,000/mm3 in the absence of apparent
bleeding.
We suggest prophylactic platelet transfusion when
counts are < 20,000/mm3 if the patient has a
significant risk of bleeding. Higher platelet counts
(≥50,000/mm3) are advised for active bleeding,
surgery, or invasive procedures.
31. Use plasma therapies in children to correct
sepsis-induced thrombotic purpura disorders,
including progressive disseminated
intravascular coagulation, secondary
thrombotic microangiopathy, and thrombotic
thrombocytopenic purpura.
33. H. Glycemic Control:
Control hyperglycemia using a similar target as
in adults ≤ 180 mg/dL. Glucose infusion
should accompany insulin therapy in
newborns and children.
34. I.Diuretics and Renal Replacement Therapy:
Use diuretics to reverse fluid overload when
shock has resolved, and if unsuccessful then
continuous venovenous hemofiltration (CVVH)
or intermittent dialysis is suggested to prevent
> 10% total body weight fluid overload.
