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Shock in children-revppt


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Shock in children-revppt

  1. 1. SHOCK IN CHILDREN Sanju Susan Samuel Fellow-Pediatric Critical Care Medicine
  2. 2. OBJECTIVES  Definition  Physiology  Classification of Shock  Common Etiologies  Recognition and Assessment  Management
  3. 3. 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.
  4. 4. igure 1. FACTORS AFFECTING OXYGEN DELIVERY DO2 CaO2 CO SV HR Oxygenation Hgb A-a gradient DPG Acid-Base Balance Blockers Competitors Temperature Drugs Conduction System Ventricular Compliance EDV ESV Contractility CVP Venous Volume Venous Tone Afterload Blockers Temperature Competitors Drugs Autonomic Tone Metabolic Milieu Ions Acid Base Temperature Drugs Toxins Influenced By Influenced By Influenced By Influenced By
  5. 5. What is needed to maintain Perfusion??  PUMP- Heart  PIPES- Vessels  FLUID- Blood  Pump Failure  Pipe Failure  Loss of Volume How can Perfusion fail??
  6. 6. 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
  7. 7. So-what happens?? Anaerobic MetabolismAnaerobic MetabolismAnaerobic Metabolism GLUCOSE METABOLISM 2 LACTIC ACID 2 ATP HEAT (32 kcal) Aerobic MetabolismAerobic MetabolismAerobic Metabolism 6 O2 GLUCOSE METABOLISM 6 CO2 6 H2O 36 ATP HEAT (417 kcal)
  8. 8. 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 .
  9. 9. RECOGNITION & ASSESSMENT  Respiratory - Quality of Respirations - Auscultatory Findings  Cardiovascular - Pulse - Blood Pressure, Pulse pressure  Skin -Color -Capillary Refill -Temperature -Moist/ Dry
  10. 10. 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
  11. 11. SIGNS OF SHOCK  Early Signs 1. Tachycardia 2. Normal blood pressure 3. Mildly delayed capillary refill 4. Fussy child
  12. 12. Signs of Shock..  Late Signs 1. Persisting tachycardia or bradycardia 2. Hypotension- LATE sign!! 3. Poor capillary refill 4. Altered mental status 5. Irregular breathing pattern 6. Poor muscle tone 7. Lower limit of SBP=70 + (2 x age in years)
  13. 13. FUNCTIONAL CLASSIFICATION OF SHOCK Hypovolemic Distributive Cardiogenic Obstructive Septic Whole blood loss Plasma loss Fluid/ electrolyte losses Septic Anaphylaxis Spinal anesthesia Infectious CMP Carditis Metabolic Arrythmia Pericardial tamponade Tension Pneumothorax Pulmonary HTN
  14. 14. 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.
  15. 15. 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.
  16. 16. Solution makeup Osmol Glucose Na+ Cl- K+ Ca+ Lactate  5% D/W 278 50g/l 0 0 0 0 0  10%D/W 556 100g/l 0 0 0 0 0  .45% NS 154 0 77 77 0 0 0  .9% NS 308 0 154 154 0 0 0  LR 274 0 130 109 4 1.5 28 Na, Cl, K, Ca, and lactate are measured in mmol/liter.
  17. 17. 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 (Carcillo et al., Pediatrics 2009)(Slides are courtesy of Dr. Carcillo)
  18. 18. 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
  19. 19. Pathophysiology LV able to eject less volume of bld/ beat Dec. Stroke Volume Increased Venous Return Increased EDV Increased LV diastolic filling pressure Backflow from LV to lungs Dec.C.O Increased O2 extraction by tissues Arterial O2 desaturation
  20. 20. Etiology of Cardiogenic Shock  Dysrrhythmias  Cardiomyopathies  Congenital Heart Disease  Trauma Hypoxic-Ischemic event Infectious Metabolic Connective Tissue Disorder NM disorders Toxins Others
  21. 21. Recognizing Cardiogenic Shock History Physical Examination CXR  Excessive Resp effort  Prolonged feeding time  Poor weight gain  Excessive sweating  Frequent resp. tract infections  Inc HR, Inc RR  Gallop  Cold extremites, weak peripheral pulses  Rales  Dyspnea, cyanosis  Hepatomegaly  Neck V dsitension  Peripheral edema  Hypotension Cardiomegaly Pulm venous congestion Hyperinflation
  22. 22. Managing Cardiogenic Shock… Minimize Myocardial O2 demands Maximize Myocardial Performance Exclude & Explore Intubation Maintain normothermia Provide sedation Correct anemia Correct Dysrhythmias Optimize Preload Improve Contractility Reduce Afterload Exclude traumatic or CHD Explore surgical options
  23. 23. OBSTRUCTIVE SHOCK  Normal Preload  Normal myocardial function  Inadequate C.O.  Etiology  Recognize and treat underlying cause!! Tension Pneumothorax Pulmonary/ Systemic HTN Congenital/ Acquired outflow obstructions Ac. Pericardial Tamponade
  24. 24. 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  Management: Recognize and treat underlying cause Anaphylaxis Spinal or Epidural anesthesia Disruption of spinal cord Iatrogenic
  25. 25. SIRS/Sepsis/Septic shock Mediator release: exogenous & endogenous Maldistribution of blood flow Cardiac dysfunction Imbalance of oxygen supply and demand Alterations in metabolism SEPTIC SHOCK
  27. 27. SIRS Sepsis Severe Sepsis Septic Shock 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
  28. 28. Warm Shock Cold Shock Fluid-Refractory/ Dopamine resistant Catecholamine Resistant Refractory Shock Early, compensated 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 Late, 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 Lab Data -Metab. Acidosis -Hypoxia -Coagulopathy -Hypoglycemia Persistance of shock despite > 60cc/kg fluid resuscitation Persistance of shock despite Dopamine at >10mcg/kg/mn 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
  29. 29. Early Goal directed therapy in treatment of sepsis and septic shock- Rivers et al., NEJM, Nov 2001
  30. 30.  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 Antibiotic Guidelines in Sepsis by Suspected SiteAntibiotic Guidelines in Sepsis by Suspected Site
  31. 31. HEMODYNAMIC VARIABLES IN SHOCK STATES ↑ or ↔↑↓↓↑↑↓↓Septic: Late ↓↓↔ Or ↓↓↓↓↑↑↑Septic: Early ↔ Or ↓↔ Or ↓↔ Or ↓↓↓↓↑↑Distributive ↑↑↑↑↔ Or ↓↑↓Obstructive ↑↑↑↑↔ Or ↓↑↑↑↓↓Cardiogenic ↓↓↓↓↓↓↔ Or ↓↑↑Hypovolemic CVPWedgeMAPSVRCO
  32. 32. B.P or Systemic Vascular Resistance Therapies for Hemodynamic Patterns in Shock State
  33. 33. Therefore, the Basics….  Stabilize respiration  Assess perfusion  Fluid administration  IV Access  Vasopressors  Inotropic therapy  Red blood cell transfusions if needed
  34. 34. References  Pediatric Critical Care: Fuhrman, Zimmerman  Surviving Sepsis Guidelines  E-medicine  Uptodate online  SCCM website