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10-Shock(1).pptx
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- 2. Sabnam, a 2year old child came to ER with multiple episodes of loose stool and vomiting. On arrival her vitals were : •HR: 140 bpm •RR: 50/ min •BP: 60/40 mmHg •CRT= 4 seconds •SpO2: 94% in room air What are the problems with this child?
- 3. Definition of shock •Shock is defined as a physiological state characterized by inadequate tissue perfusion to meet metabolic demand and tissue oxygenation.
- 4. Classification of shockin children •Hypovolemic shock •Distributive shock •Cardiogenic shock •Obstructive shock
- 5. Difference between compensatedand hypotensive shock Compensated shock Hypotensive shock Tachycardia, feeble pulse, cold peripheries, normal BP no organ dysfunction Tachycardia, feeble pulse, cold peripheries, low BP, signs of organ dysfunction
- 6. Clinical features ofShock Signs Affected organs Compensatory mechanism Tachycardia Heart Increased heart rate Cold, pale, mottled, diaphoretic Skin Increased SVR Delayed CRT Peripheral circulation Weak peripheral pulses, narrow pulse pressure Pulses Oliguria Kidney Increased renal and splanchnic vascular resistance Vomiting, ileus Intestine Altered mental status, disorientation, anxiety, restlessness, or coma Brain Cerebral autoregulation
- 7. Clinical features ofHypovolemic Shock • Quiet tachypnea • Tachycardia • Weak or absent peripheral pulses, Normal or weak central pulses • Delayed CRT • Compensated or hypotensive shock with narrow pulse pressure • Cold, pale, mottled skin/ Dusky/pale distal extremities • Altered level of consciousness/ Decreasing level of consciousness as shock progresses • Oliguria
- 8. Clinical features ofseptic shock • Hyperthermia/ hypothermia • Features of poor perfusion: Low BP, CRT prolonged, mottling of skin, fast and weak pulse • Decreased urine output • Altered mental status
- 9. Clinical feature ofCardiogenic shock • Maintainable airway unless altered level of consciousness • Tachypnea, ↑ WOB • Tachycardia • Weak/absent peripheral pulses • Normal or weak central pulses • Prolonged CRT with cold extremities • Normal or low BP with a narrow pulse pressure • Signs of congestive heart failure • Cyanosis • Cold, pale, mottled skin
- 10. Investigations • In allkinds of Shock CBC, RFT, Electrolytes, ABG, urine RME, Stool RME • Important investigations in: oHypovolemic: RFT, Electrolytes, ABG, urine RME, Stool RME oSeptic: ESR, CRP, Blood C/S, Urine RME, URINE C/S, CXR oCardiogenic: ABG, cardiac enzymes, lactate, TFT, CXR, ECG, ECHO
- 11. Basic rules formanagement of shock in children • Optimize oxygen content of the blood • Improve volume and distribution of cardiac output • Reduce oxygen demand • Correct metabolic derangements
- 12. General management ofshock • Positioning of child & Support airway, oxygenation, and ventilation • Establish vascular access: peripheral, intraosseous, central • Fluid resuscitation: oIsotonic crystalloid (Normal Saline or Ringer’s Lactate) @ 20ml/kg IV bolus oVolume and rate of administration should be decided based on types of shock
- 13. General management ofshock (Continued) • Monitor vitals & Reassessment: trends of vitals, response to therapy • Laboratory investigations • Medications: Early antibiotics administration in septic shock Inotropes/Vasodilators/Vasopressors
- 14. Management of hypovolemicshock • Identify the type of volume loss Management Type In all patients non- hemorrhagic hemorrhagic Rapidly infuse isotonic crystalloid (Normal saline Or Ringer’s lactate) @ 20ml/kg boluses and repeat as needed. Isotonic crystalloid @ 20ml/kg (up to 60ml/kg) Approximately 3ml of crystalloid is needed for every 1ml of blood loss. In patients with crystalloid- refractory hemorrhagic shock, blood transfusion should be done @10ml/kg.
- 15. Management of hypovolemicshock • Replace volume deficit: Determine the grade of dehydration and Replace the volume deficit & replace and prevent ongoing losses • Correct metabolic derangements: hypoglycemia, hyponatremia etc. • Consider laboratory investigations as mentioned above • Vasoactive agents Not routinely indicated Profound hypotension may require short-term administration of vasoactive agents such as epinephrine
- 16. Management of SepticShock • Step 1: 0-5 min recognize decreased perfusion/call for help oxygen management • Step 2: 0-60min IV access (if 3 attempts fail then IO) Send blood/ urine test If features of shock: 1st bolus @10-20ml/kg reassess the child after each bolus (max. 40-60ml/kg) 1st dose of empirical antibiotics within 1 hr after blood CS Correct hypoglycemia Place urinary catheter
- 17. Management of SepticShock contd Step 3: Fluid Refractory Shock • Start inotropes / vasoconstrictors • Differentiate between Cold and Warm shock • Epinephrine in cold shock/ Nor-epinephrine in warm shock • Dopamine if Epinephrine & Nor-epinephrine is not available • Dobutamine: if BP is normal or high with poor peripheral circulation • IV Hydrocortisone
- 18. Management of CardiogenicShock Supplemental oxygen/NIV/IMV Small isotonic fluid boluses @ 5-10 ml/kg should be given slowly over 10-20 minutes Monitor signs of fluid overload/pulmonary edema: o Respiratory rate and work of breathing o Jugular vein distension o Tender hepatomegaly o Basal rales o Gallop rhythm
- 19. Management of CardiogenicShock (Contd) Medications: o Normotensive: diuretics and vasodilators or inodilators o Shock: vasodilators, inotropes, and inodilators (milrinone)
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- 21. What is the diagnosisof our case? How do you manage this child? Sabnam, A 2 year old child came to ER with multiple episodes of loose stool and vomiting. On arrival her vitals were : •HR 140 bpm, •RR 50/ min, •BP 60/40mmhg •CRT=4 sec •SpO2: 94% in room air
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