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Septic shock
Septic shock
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  1. 1. • Cardiogenic shock — Cardiogenic shock results from pump failure, manifested physiologically as decreased systolic function and depressed cardiac output . • Cardiogenic shock is uncommon among children as compared with adults, among whom ischemic heart disease is the major cause. • Cardiac causes may result from inadequate contractility or excessively fast or slow rhythms: 21/4/2022 1 Cardiogenic Shock
  2. 2. Etiology • Primary myocardial injury, • Arrhythmias, • Cardiomyopathy, • Myocarditis, • Congenital heart disease with heart failure, before or after surgery, including heart transplantation • Sepsis, • Poisoning. 21/4/2022 2
  3. 3. • Ventricular fibrillation and pulseless ventricular tachycardia abolish cardiac output, while diminished ventricular filling time. • Prolonged unrecognized supraventricular tachycardia . • Bradyarrhythmias and complete heart block can result in shock caused by chronotropic insufficiency. 21/4/2022 3 Arrhythmias
  4. 4. Blunt cardiac injury Myocardial contusion Traumatic aneurysm Traumatic septal defect Chamber rupture Valvular rupture 21/4/2022 4
  5. 5. • Drug toxicity : Beta blockers, Barbiturates, Chemotherapeutic agents, Calcium channel blockers • Metabolic derangements : Acidosis,Hyperkalemia ,Hypocalcemia • Hypothermia • Hypoxic or anoxic/ischemic injury 21/4/2022 5 Others ....
  6. 6. History  Cardiogenic shock – History of heart disease , history of palpitations, signs of heart failure.  Infant : poor feeding, poor appetite and can quickly progress to lethargy , Older child : fatigue ,difficulty of breathing or chest pain , as shock progress may experience syncope . 21/4/2022 6
  7. 7. The presenting signs. • Tachypnea, Tachycardia, • Cool extremities, delayed capillary filling time, • Poor peripheral and/or central pulses, • Declining mental status, coma • Decreased urine output, • Raised JVP ,crackles, hepatomegally, 21/4/2022 7
  8. 8. • Mortality exceeds 50% so focus on : • Rapid diagnosis, • Restoration of coronary blood flow through early revascularization, • Complication management, and • Maintenance of end-organ homeostasis. 21/4/2022 8 Management
  9. 9. Management • Initial resuscitation  stabilizing the airway ,breathing, circulation with establishment of vascular access  continues monitoring of vital signs, pulse oximetry saturation  chest compression indicated for bradicardia with poor perfusion 21/4/2022 9
  10. 10. In uncompensated cardiogenic shock NS bolus 5-10ml /kg over 10 to 20 mins Dopamine 10mcg/kg/min and/or Doubutamine 10- 15mcg/kg/min infusion.  Mechanical ventilation if patient in respiratory distress or critically ill. 21/4/2022 10
  11. 11.  In compensated cardiogenic shock Frusamide infusion 0.05-0.1mg/kg/h Add milirnon 0.1 -1mcg/kg/min Increased afterload state Chx by normal HR, good central pulse, weak peripheral pulse, cold periphery, BP normal to high, hyperlactemia Increase infusion rate of milirnon. 21/4/2022 11
  12. 12. • After milirnon infusion : tachycardia, good pulse, warm periphery, decrease UOP, slightly low BP and hyperlactemia consider hypovlumia and administer 5- 10ml/kg fluid bolus • When optimal cardiac out put is achieved: good normal pulse, warm extremity, good UOP, normal BP and normal lactate maintain the same inotropic support. 21/4/2022 12
  13. 13. Treatment of Precipitating factor Arrhythmia, Drug toxicity , Underlying infection, Anemia, Metabolic derangements, 21/4/2022 13
  14. 14. Distributive shock • Refers to a condition in which systemic vascular resistance is initially decreased. • It may occur as the result of sepsis, anaphylaxis, or neurologic injury. • Associated with increased capillary permeability with loss of plasma from the intravascular space into the tissues. • Significant decreases in both preload and after load 21/4/2022 14
  15. 15. Anaphylacyic shock  Cutaneous : sudden onset of generalized urticaria, angioedema, flushing, pruritus. • However, 10 to 20% of patients have no skin findings.  Respiratory : Stridor and wheezing  Cardiovascular : Decreased Blood Pressure 21/4/2022 15
  16. 16. • Air way management  Place patient in recumbent position, if tolerated, and elevate lower extremities.  Immediate intubation if evidence of impending airway obstruction from angioedema.  Oxygen: Give 8 to 10 L/minute via facemask or up to 100% oxygen, as needed. 21/4/2022 16 Management
  17. 17. • Fluid managment  Normal saline rapid bolus: Rapid infusion of 20 mL/kg. Re-evaluate and repeat fluid boluses (20 mL/kg), repeat as needed. • Epinephrine  IM epinephrine (1 mg/mL preparation): 0.01 mg/kg should be injected intramuscularly in the mid-outer thigh. the maximum is 0.5 mg per dose. If there is no response or inadequate, it can be repeated in 5 to 15 minutes 21/4/2022 17
  18. 18. Treatment of Refractory symptoms: • Epinephrine infusion: In patients with inadequate response to IM epinephrine and IV saline, give epinephrine continuous infusion at 0.1 to 1 mcg/kg/minute, titrated to effect. • Vasopressors: Patients may require large amounts of IV crystalloid to maintain blood pressure and may require a second vasopressor • Albuterol: For bronchospasm resistant to IM epinephrine, give albuterol 0.15 mg/kg (minimum dose: 2.5 mg) in 3 mL saline via nebulizer. Repeat, as needed. 21/4/2022 18
  19. 19. Obstructive shock • Describes physical obstruction of systemic blood flow from the heart which causes abrupt impairment of cardiac output. • The acute presentation may quickly progress to cardiac arrest. • Children with severe respiratory distress and signs of circulatory compromise may have obstructive shock. 21/4/2022 19
  20. 20. Etiology • Tension pneumothorax, • Cardiac tamponade, • Hemothorax, • Pulmonary embolism, • Ductal-dependent congenital heart defects 21/4/2022 20
  21. 21. Management  Adressing the primary insult  pericardiocentesis for pericardial effusion  pleurocentesis for pneumothorax  Thrombectomy/thrombolysis for pulmonary embolism  prostaglandin infusion for ductus-dependent cardiac lesions.  Fluid resuscitation  There is often a “last-drop” phenomenon associated with some obstructive lesions. 21/4/2022 21
  22. 22. Shock in SAM patients • Sunken eyes, lethargy, and tenting of skin may occur from malnutrition alone and can cause clinicians to overestimate the degree of dehydration. Diagnosis of Shock  lethargic or unconscious and cold hands • Plus either:  slow capillary refill (longer than 3 sec) or weak fast pulse. 21/4/2022 22
  23. 23. Management  Give oxygen  Give sterile 10% glucose (5 mL/kg) by IV  Give IV fluid at 15 mL/kg over 1 hr, if improvement isues repeat IV 15 mL/kg for 1 more hr.  Switch to oral or nasogastric rehydration with ReSoMal, 5-10 mL/kg alternate hr with F-75 until fully rehydrated. 21/4/2022 23
  24. 24. Refractory cases If there are no signs of improvement : ? Septic Give maintenance fluid IV (4 mL/kg/hr) while waiting for blood Transfuse 10 mL/kg fresh whole blood slowly over 3 hr. If signs of heart failure, give 5-7 mL/kg packed cells . Give furosemide 1 mL/kg IV at the start of the transfusion 21/4/2022 24
  25. 25. PITFALLS  Failure to recognize nonspecific signs of compensated shock  Inadequate monitoring of response to treatment  Inappropriate volume for fluid resuscitation  Failure to reconsider possible causes of shock for children who are getting worse.  Failure to recognize and treat obstructive shock. 21/4/2022 25
  26. 26. 21/4/2022 26
  27. 27.  A 5 year old child is brought to the ED after sustained blunt chest trauma on P/E he is conscious, no bleeding from any site ,V/S BP is 60/40, PR =80 bts/min ,RR=45 brths/min , T=36.6 c , SPO2 70% Capillary refill is <2sec , Resp : IC / SC Retraction, Hyperesonant left chest , Tracheal shift to the right . Cvs : Distended neck vein How do you manage ? 21/4/2022 27
  28. 28. Clinical Trial • However, evidence suggests that the WHO recommendations for fluid resuscitation in severely malnourished may be too restrictive. For example, in an observational study of fluid resuscitation in 149 severely malnourished children with cholera and severe dehydration, infusion of approximately 20 mL/kg per hour of an isotonic saline solution over four to six hours was not associated with heart failure in any patient, and all patients survived . 21/4/2022 28
  29. 29. Reference • Up-to-date • Nelson 2021 edition • Pediatrics Advanced life support guideline • SAM guideline 2020 , 3rd edition 21/4/2022 29

Editor's Notes

  • Cardiomyopathies – Causes of myopathic pump failure include familial, infectious, infiltrative, and idiopathic cardiomyopathies.
  • during ventricular tachycardia decreases preload and stroke volume substantially.
    (as can occur with the initial presentation for infants) can decrease cardiac output
    Cardiac arrhythmias (eg, supraventricular or ventricular tachycardia) should be addressed prior to fluid resuscitation
  • caused by the combination of decreased cardiac output and compensatory peripheral vasoconstriction
    Additional findings include tachycardia out of proportion to fever or respiratory distress, cyanosis unresponsive to oxygen, and absent femoral pulses.
  • Besides revascularization, inotropes and vasodilators are potent medical therapies to assist the failing heart . vasodilators dec pre load ad or after load as well as svr
  • avoid worsening myocardial insufficiency and pulmonary edema.
    norepinephrine and vasopressin, should generally be avoided in patients with cardiogenic shock.
    Treatment with dobutamine or phosphodiesterase enzyme inhibitors can improve myocardial contractility and reduce systemic vascular resistance (afterload)
  • Results: Literature was assessed to review the use of inotropes and vasopressors in CS. Dopamine and adrenaline were associated with increased mortality and arrhythmias. Dobutamine was associated with an improvement in cardiac output, at the determinant of causing arrhythmias.

    noradrenaline was associated with a lower likelihood of arrhythmias and most importantly decreased mortality in CS.
    literature review suggests that treatment combination of the inotrope levosimendan with the vasopressor noradrenaline may be the most effective management option in CS
  • Thus, vasopressors are frequently employed along with fluid therapy, depending upon the underlying etiology as follows

    Neurogenic shock is a rare, usually transient disorder that follows acute injury to the spinal cord or central nervous system, resulting in loss of sympathetic venous tone.
  • severe hypotension ,inadq cardiac filling
  • such as coarctation of the aorta and hypoplastic left ventricle syndrome,
  • There is often a “last-drop” phenomenon associated with some obstructive lesions, in that small additional amounts of intravascular volume depletion may lead to a rapid deterioration, including cardiac arrest, if the obstructive lesion is not corrected.
  • trial of 61 children with severe malnutrition accompanied by decompensated shock in the majority of patients, administration of 30 to 40 mL/kg of crystalloid fluids over two hours failed to reverse shock in over half of patients and was accompanied by high mortality

  • (ie, unexplained tachycardia, abnormal mental status, or poor skin perfusion)