Management of shock

1. Management of Shock
Dr. ATIULLAH KHAN

2. DIAGNOSIS
* Shock is diagnosed clinically on the basis of a thorough history and
physical exam.

3. DIFFERENTIAL DIAGNOSIS OF THE CHILD
PRESENTING WITH SHOCK
• Bleeding shock —History of trauma ,Bleeding site Dengue shock
syndrome —Known dengue outbreak or season, History of high
grades fever ,Purpura
• Cardiac shock —History of heart disease , congested neck veins and
liver
• Septic shock —History of febrile illness ,Very ill child Known outbreak
of meningococcal infection
• Shock associated with severe dehydration —History of profuse
diarrhea ,Known cholera outbreak

4. LABORATORY FINDINGS
* Thrombocytopenia & anemia
* Prolonged PT & PTT
* Reduced fibrinogen level
• Elevated neutrophil count and immature forms, vacuolation of
neutrophils, toxic granulations,
and Döhle bodies can be seen with infection
* Neutropenia & leukopenia are ominous sign of overwhelming sepsis.

5. LABORATORY FINDINGS
*Glucose dysregulation (hyper or hypoglycemia) is a common stress
response
*Electrolyte abnormalities are hypocalcemia, hypoalbuminemia, and
metabolic acidosis.
*Renal and/or hepatic function may be abnormal
*Patients with ARDS or pneumonia have impairment of oxygenation
(decreased PaO2) as well as ventilation (increased PaCO2) in the later
stage of lung injury.

6. LABORATORY FINDINGS
*The hallmark of uncompensated shock is an imbalance between O2
delivery and O2 consumption.
*This state manifests clinically by increased lactic acid production (high
anion gap, metabolic acidosis) due to anaerobic metabolism and a low
mixed venous oxygen saturation

7. LABORATORY FINDINGS
• Serum lactate measurement along with mixed venous oxygen
saturation may be used as a marker for the adequacy of oxygen
delivery and the effectiveness of therapeutic interventions.

8. TREATMENT

9. INITIAL MANAGEMENT
*Early recognition and prompt intervention are extremely important in the
management of all forms of shock.
*Regardless of the cause: ABC’s
*First assess airway patency, ventilation, then circulatory system
*Respiratory Performance
*Respiratory rate and pattern, work of breathing, oxygenation (color), level
of alertness
*Circulation
*Heart rate, BP, perfusion, and pulses, liver size
*CVP monitoring may be helpful

10. INITIAL MANAGEMENT
• Airway management
*Always provide supplemental oxygen
*Endotracheal intubation and controlled ventilation is suggested if
respiratory failure or airway compromise is likely
*elective is safer and less difficult
*decrease negative intrathoracic pressure
*improved oxygenation and O2 delivery and decreased O2
consumption

11. • Neonates and infants in particular may have profound glucose
dysregulation in association with shock
• *Glucose levels should be checked routinely and treated
appropriately, especially early in the course of the illness.
INITIAL MANAGEMENT

12. *Given the predominance of sepsis and hypovolemia as the most
common causes of shock in the pediatric population, most
therapeutic regimens are based on guidelines established in these
settings.
*Immediately after establishment of IV or IO access, aggressive, early
goal-directed therapy (EGDT) should be initiated unless there
significant concerns for cardiogenic shock as an underlying
pathophysiology.
INITIAL MANAGEMENT

13. *Rapid IV administration of 20 mL/kg isotonic saline or, less often
colloid should be initiated in an attempt to reverse the shock state
*Bolus should be repeated quickly up to 60-80 mL/kg.
*Rapid fluid resuscitation using 60-80 mL/kg or more is associated with
improved survival without an increased incidence of pulmonary
edema. INITIAL MAN
INITIAL MANAGEMENT

14. INITIAL MANAGEMENT
*Fluid resuscitation in increments of 20 mL/kg should be titrated to
normalize HR, urine output (to 1 mL/kg/hr),
capillary refill time(<2seconds), and mental status.
*Normalization of BP alone is not a reliable endpoint for assessing the
effectiveness of resuscitation.

15. *Although the type of fluid (crystalloid vs colloid) is an are of debate,
fluid resuscitation in the first hour is unquestionably essential to
survival in septic shock, regardless of the fluid type administered.
*If shock remains refractory following 60-80 mL/kg resuscitation,
inotrope therapy should be instituted while additional fluid are
administered
*Inotropic and vasoactive drugs are not a substitute for fluid,however...
Can have various combinations of hypovolemic and septic and cardiogenic
shock
*May need to treat poor vascular tone and/or poor cardiac function
INITIAL MANAGEMENT

16. CARDIOVASCULAR DRUG TREATMENT OF
SHOCK

17. VASODILATORS/AFTERLOAD REDUCERS

18. GOAL-DIRECTED THERAPY OF ORGAN
DYSFUNCTION IN SHOCK

19. GOAL-DIRECTED THERAPY OF ORGAN
DYSFUNCTION IN SHOCK

20. GOAL-DIRECTED THERAPY OF ORGAN
DYSFUNCTION IN SHOCK

21. GOAL-DIRECTED THERAPY OF ORGAN
DYSFUNCTION IN SHOCK

22. GOAL-DIRECTED THERAPY OF ORGAN
DYSFUNCTION IN SHOCK

24. SEPTIC SHOCK
*Early administration of broad spectrum antimicrobial agents is
associated with a reduction in mortality.
*Neonates should be treated with ampicillin plus cefotaxime and/or
gentamicin.
Acyclovir should be added if herpes simplex virus is suspected clinically.
*In infants and children
Community acquired N. meningitides can be treated with 3rd generation
cephalosporin (Ceftriaxone or cefotaxime) or high dose penicillin.
H. influenzae can be treated with ceftrixone or cefotaxime
The presence of resistant S. pneumoniae often requires the addition of
vancomycin

25. SEPTIC SHOCK
• Suspicious of community or hospital acquired MRSA infection
warrants the coverage with vancomycin.
• If intra-abdominal process is suspected, anaerobic coverage should be
included with an agents such as Metronidazole, Clindamycin, or
piperacillin-tazobactam.
• Nosocomial sepsis should generally be treated at least 3rd or 4th
generation cephalosporin or piperacillin-tazobactam. An aminoglycoside
should be added as the clinical situation warrants.
*Vancomycin should be added to the regimen if the patient has an
indwelling medical device, gram positive cocci are isolated from the blood,
or MRSA is suspected or as empiric coverage for S. pneumoniae.

26. SEPTIC SHOCK
• Empirical coverage for fungal infections should be considered for
selected immunocompromised patients.
These broad, generalized recommendations must be tailored to the
individual clinical scenario and to the local resistance pattern of the
community and/or hospital

27. HYPOVOLEMIC SHOCK
• Mainstay of therapy is fluid
*Goals
Restore intravascular volume
Correct metabolic acidosis
Treat the cause
Degree of dehydration often underestimated
Reassess perfusion, urine output, vital signs...
Isotonic crystalloid is always a good choice

28. • Regardless of the etiology of shock, metabolic status should be
meticulously maintained.
*Electrolytes should be monitored closely and corrected as needed.
*Hypoglycemia is common and should be promptly treated.
Hypocalcemia which may contribute to myocardial dysfunction,
should be treated.

29. STEROIDS
• Hydrocortisone replacement may be beneficial in pediatric shock.
*Up t0 50% of critically ill patient may have absolute or relative adrenal
insufficiency.
Patients at increased risk for adrenal insufficiency include those with
congenital adrenal hyperplasia, abnormalities of hypothalamic-
pituitary axes, recent therapy with corticosteroids, and should receive
stress doses of hydrocortisone.
*Steroids may also be considered in patients with shock that is
unresponsive to fluid resuscitation and catecholamines.

30. THANK YOU