The document presents an extensive overview of shock, including its definition, types (hypovolemic, cardiogenic, distributive, obstructive, and septic shock), and pathophysiology. It describes the compensatory mechanisms the body engages to maintain tissue perfusion, as well as the progression from compensated to irreversible shock. Key clinical findings and criteria for diagnosing shock and multiple organ dysfunction syndrome (MODS) in pediatric patients are also detailed.

1. Presentation on Shock
DR. SHAHED IQBAL

2. Definition
SHOCK: Inadequate organ perfusion to meet
the tissue’s oxygenation demand.

3. Types of shock
Hypovolemic shock
Cardiogenic shock
Distributive shock
Obstructive shock
Septic shock

4. Decreased intravascular volume
Cardiac output
Shift of interstitial fluid
Aldosterone, ADH
Splenic discharge
Volume
Cardiac output
More volume loss
Tissue perfusion
Cardiac output
Impaired cellular metabolism
SVR, heart rate Catecholamine
release
Systemic and pulmonic
pressures

5. Disruption of sympathetic nervous system
Loss of sympathetic tone
Venous and arterial vasodilatation
Decreased venous return
Decreased stroke volume
Decreased cardiac output
Decreased cellular oxygen supply
Impaired tissue perfusion
Impaired cellular metabolism
Pathophysiology of Neurogenic
Shock

6. Antigen (allergen)
Antibody (IgE)
Complement, histamine,
Kinins, prostaglandins
Capillary permeability
Tissue perfusion
Extravasation of
intravascular fluids
SVR
Edema
Peripheral
Vasodilation
Relative hypovolemia
Cardiac Output
Impaired cellular
metabolism
Constriction of extravascular
Smooth muscle (bronchoconstricti
Larygospasm, gastrointestinal
Cramps)

7. METABOLISM
AEROBIC METABOLISM
6 O₂
GLUCOSE
6 CO₂
6 H₂O
36 ATP
HEAT (417 kcal)

8. GLUCOSE
HEAT (32 kcal)
2 ATP
2 LACTIC ACID
ANAEROBIC METABOLISM
METABOLIS
M

9. ANAEROBIC? So What?
Inadequate
Energy
Production
Anaerobic
Metabolism
Lactic Acid
Production
Metabolic
Failure Cell Death!
Metabolic
Acidosis
Inadequate
Cellular
Oxygenation

10. PATHOPHYSIOLOGY OF SHOCK SYNDROME
Cells switch from aerobic to anaerobic metabolism
lactic acid production
Cell function ceases & swells
membrane becomes more permeable
electrolytes & fluids seep in & out of cell
Na+/K+ pump impaired
mitochondria damage
cell death

11.  Compensated
 The body’s compensatory mechanisms are able
to maintain some degree of tissue perfusion.
 Decompensated
 The body’s compensatory mechanisms fail to
maintain tissue perfusion (blood pressure falls).
 Irreversible
 Tissue and cellular damage is so massive that the
organism dies even if perfusion is restored.
Stages of Shock

12. • Inadequate systemic oxygen delivery activates autonomic
responses to maintain systemic oxygen delivery
• Sympathetic nervous system
• NE, epinephrine, dopamine
• Causes vasoconstriction, increase in HR, and increase of cardiac contractility
(cardiac output)
• Renin-angiotensin axis
• Water and sodium conservation and vasoconstriction
• Increase in blood volume and blood pressure
Compensate ? How?

13. Hormonal: Antidiuretic Hormone
Osmoreceptors in hypothalamus stimulated
ADH released by Posterior pituitary gland
Vasopressor effect to increase BP
Acts on renal tubules to retain water
COMPENSATION CONTINUE

14. SEPTIC SHOCK
CardiogenicDistributive
Hypovolemic

15. Insult, injury or infection
Local inflammatory reaction
Release of mediators
Systemic inflammatory response
Diffuse endothelial injury,
vasodilatation
and increased capillary permeability
Progressive vasodilatation and maldistribution of blood flow
Organ hypoperfusion
Multiple organ dysfunction syndrome
PATHOGENESIS OF SEPTIC SHOCK

16. Sepsis or tissue hypoxia with lactic acidosis
Nitric oxide synthase ATP, H⁺, lactate
In vascular smooth muscle
Vasopressin secretion
Nitric oxide
Open Kca
cGMP Cytoplasmic Ca²⁺
Phosphorylated myosin
Vasodilation
Open Kᴀᴛᴘ
Vasopressin stores
Plasma
Vasopressin

17. CRITERIA FOR ORGAN DYSFUNCTION

18. Cardiovascular
Respiratory
Neurologic
Hematologic
Renal
Hepatic

19. Despite administration of isotonic intravenous fluid bolus > 60
ml/kg in 1 hour: Decrease in BP ( hypotension) <5th percentile
for age or systolic BP <2 SD below normal for age
OR
Need for vasoactive drug to maintain BP in normal range
(dopamine>5μg/kg/min or dobutamine,epinephrine,or
norepinephrine at any does)
OR
Two of the following:
Unexplained metabolic acidosis: base deficit >5.0 mEq/L
increased arterial lactate:>2X upper limit of normal
Oliguria: urine output <0.5ml/kg/hr
Prolonged capillary refill:>5 sec
Core to peripheral temperature gap >3⁰C
Cardiovascular

20. MAP <5th PERCENTILE FOR AGE
LOWEST ACCEPTABLE SBP = 70 + [2x AGE IN YEARS]
AGE LOWEST ACCEPTABLE SBP
TERM NEONATE 60
INFANT 1-12 MONTHS 70
CHILDREN 1-10 YRS 70 +[2x AGE IN YEARS]
CHILDREN >10 YRS 90
HYPOTENSION

21. • Do you remember how to
quickly estimate blood
pressure by pulse?
60
80
70
90
• If you palpate a pulse,
you know SBP is at least this number
Shoc
k

22. Pa0₂/Fi0₂ ratio <300 in absence of cyanotic heart disease or
pre-existing lung disease
OR
PaC0₂ >65 torr or 20 mm Hg over baseline PaC0₂
OR
Proven need for >50% Fi0₂ to maintain saturation >92%
OR
Need for nonelective invasive, noninvasive mechanical
ventilation
Respiratory

23. GCS Score <11
OR
Acute change in mental status with a decrease in GCS score
>3 points from abnormal baseline.
Neurologic

24. EYE OPENING
SPONTANEOUS 4
TO VOICE 3
TO PAIN 2
NONE 1
VERBAL RESPONSE
OLDER CHILDREN INFANTS & YOUNG CHILDREN
ORIENTED 5 APPROPIATE WORDS; SMILE,
FIXES,FOLLOWS
5
CONFUSED 4 CONSOLABLE CRYING 4
INAPPROPIATE 3 PERSISTENTLY IRRITABLE 3
INCOMPREHENSIBLE 2 RESTLESS, AGITED 2
NONE 1 NONE 1
MOTOR RESPONSE
OBEYS 6
LOCALIZES
PAIN
5
WITHDRAWS 4
FLEXION 3
EXTENSION 2
NONE 1

25. Platelet count <80,000/mm³ or a decline of 50% in the platelet
count from the highest value recorded over the last 3 days (for
patients with chronic hematologic or oncologic disorders)
OR
INR>2
Hematologic

26. Serum creatinine >2X upper limit of normal for age or 2-fold
increase in baseline creatinine value
Renal

27. Total bilirubin >4 mg/dL (not applicable for newborn)
Alanine transaminase level 2x upper limit of normal for ag
Hepatic

28. INTERNATIONAL CONSENSUS
DEFINITIONS
FOR
PEDIATRIC SEPSIS

29. MODS
INFECTION
SIRS
Sepsis
Severe Sepsis
Septic Shock
MODS

30. Suspected or proven infection or a clinical syndrome
associated with high probability of infection
INFECTION

31. 2 out of 4 criteria, 1 of which must be abnormal temperature
or abnormal leukocyte count:
1. Core Temperature >38.5°C or <36°C
(rectal, bladder, oral, or central catheter)
2. Tachycardia:
Mean heart rate >2 SD above normal for age in
absence of external stimuli, chronic drugs or painful
stimuli
OR
Unexplained persistent elevation over 0.5-4 hr
OR
In children <1 year old, persistent bradycardia over 0.5
hour (mean heart rate <10th percentile for age in absence
of vagal stimuli, β-blocker drugs, or congenital heart
Systemic inflammatory response syndrome (SIRS)

32. Systemic inflammatory response syndrome (SIRS)
3. Respiratory rate >2 SD above normal for age or acute
need for mechanical ventilation not related to
neuromuscular disease or general anesthesia
4. Leukocyte count elevated or depressed for age (not
secondary to chemotherapy) or >10% immature
neutrophils

33. SIRS plus a suspected or proven infection
Sepsis

34. Sepsis plus 1 of the following:
1. Cardiovascular organ dysfunction, defined as:
Despite >40 ml/kg of isotonic intravenous fluid in 1 hour:
Hypotension <5th percentile for age or systolic blood pressure <2 SD
below normal for age
OR
Need for vasoactive drug to maintain blood pressure
OR
2 of following:
Unexplained metabolic acidosis: base deficit >5 mEq/L
Increased arterial lactate: > 2 times upper limit of normal
Oliguria: urine output <0.5 ml/kg/hr
Prolonged capillary refill:> 5 sec
Core to peripheral temperature gap >3°C
Severe Sepsis

35. 2. Acute respiratory distress syndrome (ARDS) as defined by the
presence of a PaO₂/Fi₀₂ ratio ≤300 mm Hg, bilateral infiltrates on
chest radiograph, and no evidence of left heart failure.
OR
Sepsis plus 2 or more organ dysfunctions (respiratory, renal, neurologic,
hematologic, or hepatic)
Severe Sepsis

36. Sepsis plus cardiovascular organ dysfunctions as defined above
Septic Shock

37. Presence of altered organ function such that homeostasis cannot be
maintained without medical intervention.
Multiple organ dysfunction syndrome (MODS)

38. Clinical diagnosis of septic shock
Suspected infection
Decreased perfusion
altered mental status
decrease urine output
prolong CRT or flash CR
diminished or bounding peripheral pulse
mottled cool extremities

39. What is the first physiological factor in the development of
shock?
?
So, what are the first symptoms you would expect to find?
↑ respiratory rate
↑ heart rate
Clinical Findings

40.  What is often the second physiological response to
the development of shock?
Peripheral vasoconstriction
 What symptoms would you expect to see?
 pale skin
 cool skin
 weakened peripheral pulses
Clinical Findings

41.  As shock progresses, what physiological effects are seen?
End-organ perfusion falls
 What symptoms would you expect to see?
 altered mental status
 decreased urine output
Clinical Findings

42.  As compensatory mechanisms fully engage, what signs
and symptoms would you expect to see?
 tachycardia
 tachypnea
 pupillary dilation
 decreased capillary refill
 pale cool skin
Clinical Findings

43.  When compensatory mechanisms fail, what signs and
symptoms would you expect to see?
 hypotension
 falling SpO2
 bradycardia
 loss of consciousness
 dysrhythmias
 Mods
Clinical
Findings

44. Cold Shock Warm Shock
Heart rate Tachycardia Tachycardia
Peripheries Cool Warm
Pulses Difficult to palpate Bounding
Skin Mottled, pale Flushed
Capillary refill Prolonged Blushing
Mental state Altered Altered
Urine Oliguria Oliguria

45. Recognize
Shock
Cold Shock
Skin and extremities:
Cool
Pale
Mottled
Cyanotic
Poor cap refill

46. Recognize
Shock
Warm Shock
Skin and extremities:
Warm
Flushed
Flash Capillary Refill

47. Recognize
Shock
Poor Capillary Refill
Anything longer than
2 seconds is delayed
If you get as far as 5 sec,
you’d better be calling for help

48. Blood Count & film
Anemia
Leucocytosis
Leucopenia
Neutropenia
Thrombocytopenia
Immature Neutrophil
Vaculation of neutrophil
Toxic granulation
Döhle Bodies
Blood Culture
Lab Results
Blood Glucose
CRP

49. Lab Results
LFT
↑ PT, PTT
↑ SBR
↑ ALT
↓ ALB
RFT
Urine R/E
Urine C/S
Creatinine
Electrolyte
CXR
ABG

50. HEMODYNAMIC VARIABLES IN DIFFERENT SHOCK STATES
TYPES OF
SHOCK
CARDIA
C
OUTPU
T
SYSTEMIC
VASCULAR
RESISTANC
E
MEAN
ARTERIAL
PRESSURE
CAPILLARY
WEDGE
PRESSURE
CENTRAL
VENOUS
PRESSURE
HYPOVOLEM
IC
↓ ↑ ↔ OR↓ ↓↓↓ ↓↓↓
CARDIOGENI
C
SYSTOLIC
↓↓ ↑↑↑ ↔ OR↓ ↑↑ ↑↑
DIASTOLIC
↔ ↑↑ ↔ ↑↑ ↑
OBSTRUCTIV
E
↓ ↑ ↔ OR↓ ↑↑ ↑↑
DISTRIBUTIV
E
↑↑ ↓↓↓ ↔ OR↓ ↔ OR↓ ↔ OR↓
SEPTIC
EARLY
↑↑↑ ↓↓↓ ↔ OR↓ ↓ ↓

51. HEART RATE, RESP RATE AND BLOOD PRESSURE
VALUES BY AGE
AGE HEART
RATE/MIN
RESPIRATORY
RATE/MIN
SBP
NEONATE 120-180 40-60 60-80
1M-1YEAR 110-160 30-40 70-90
1-2YEAR 100-150 25-35 80-95
2-7YEAR 95-140 25-30 90-110
7-12YEAR 80-120 20-25 100-120

52. Fluid-refractory Shock:
Shock despite 60 cc/kg in 1st hour
Dopamine-resistant Shock:
Shock despite adequate fluid resuscitation and 10
mcg/kg/min
Catecholamine-resistant Shock:
Shock despite epinephrine or norepinephrine
Refractory Shock:
Shock despite goal-directed use of inotropic
agents, vasopressors, vasodilators, and
maintenance of metabolic and hormonal
homeostasis