The document provides a comprehensive overview of pediatric shock, detailing its definition, types, pathophysiology, diagnostic approach, and management strategies. It discusses various types of shock, including hypovolemic, cardiogenic, distributive, obstructive, and septic shock, along with their causes and unique features. Management approaches are explored for each type of shock, emphasizing fluid resuscitation, monitoring, oxygenation, and specific treatments for underlying conditions.

1. MANAGEMENT OF PEDIATRIC
SHOCK

2. • INTRODUCTION
• EPIDEMIOLOGY
• TYPES OF SHOCK
• PATHOPHYSIOLOGY
• APPROACH TO A PATIENT WITH SCHOCK
• MANAGEMENT OF PEDIATRIC SHOCK
• PROGNOSIS
OUTLINE
Shock

3. Define shock?
Types of shock?
Shock

4. Introduction
• Shock is an acute process characterized
by the body's inability to deliver
adequate oxygen to meet the metabolic
demands of vital organs and tissues.
• So, insufficient oxygen at a tissue level is
unable to support a normal aerobic
cellular metabolism, resulting in a shift to
less efficient anaerobic metabolism.
Shock

5. Epidemiology
•Shock occurs in approximately 2% of all hospitalized infants,
children, and adults in developed countries
•mortality rate varies substantially depending on the etiology and
clinical circumstances.
•Mortality is mostly due to associated complication and MODS
Shock

6. Types of Shock
• Hypovolemic
• Cardiogenic
• Distributive
• Obstructive, and
• Septic
Shock

7. Hypovolemic shock
• The most common cause of shock in children
worldwide,
• Hypovolemic shock is due to loss of blood volume,
causes decreased preload, stroke volume, and CO.
• It is most frequently caused by diarrhea, vomiting, or
hemorrhage.
Shock

8. Cardiogenic shock
• Is seen in patients with congenital heart disease (before or
after surgery, including heart transplantation) or those with
congenital or acquired cardiomyopathies, including acute
myocarditis.
• Is a problem due to the heart not being able to generate
certain amount of power to pump blood to the tissue.
Shock

9. Obstructive shock
• Stems from any lesion that creates a mechanical barrier that
impedes adequate cardiac output, which includes
- Pericardial tamponade
- Tension pneumothorax
- Pulmonary embolism
- Ductus-dependent congenital heart lesions
Shock

10. Distributive shock
• Is caused by inadequate vasomotor tone, which leads to capillary
leak and misdistribution of fluid into the interstitium.
• Includes
- Anaphylactic,
- Neurogenic,
- Septic shock
Shock

11. Cont...
• Anaphylactic shock: is due to severe systemic allergic reaction such as
food, drug allergens, bee stings, insect bites
• Neurogenic shock-loss of sympathetic vascular tone secondary to
acute spinal cord or brainstem injury or regional anesthesia
- So there will be unopposed vagal tone(leads to
bradycardia,vasodilation)
Shock

12. Septic shock
• Is often discussed synonymously with distributive shock, but
the septic process usually involves a more complex interaction
of distributive, hypovolemic, and cardiogenic shock.
Shock

13. Pathophysiology
Extracorporeal Fluid Loss
•Hypovolemic shock may be a result of direct blood loss through
hemorrhage or abnormal loss of body fluids (diarrhea, vomiting,burns,
diabetes mellitus or insipidus, nephrosis).
Lowering Plasma Oncotic Forces
•Hypovolemic shock may also result from hypoproteinemia (liver
injury, or as a progressive complication of increased capillary
permeability).
Abnormal Vasodilation
•Distributive shock (neurogenic, anaphylaxis, or septic shock) occurs
when there is loss of vascular tone—venous, arterial, or both
(sympathetic blockade, local substances affecting permeability,
acidosis, drug effects, spinal cord transection).
Shock

14. Increased Vascular Permeability
• Sepsis may change the capillary permeability in the absence of
any change in capillary hydrostatic pressure (endotoxins from
sepsis, excess histamine release in anaphylaxis).
Cardiac Dysfunction
• Peripheral hypoperfusion may result from any condition that
affects the heart’s ability to pump blood efficiently
Shock

15. COMPENSATORY MECHANISMS

16. Phases
• Compensated
– Occurs earlier in the process
– BP is maintained
– HR is elevated
• Decompensated
– Occurs late in the process
– BP is low, hypotension
– Organ damage starts to be seen
•Irreversible
– MOD has developed
Shock

17. Systemic Inflammatory Response
Syndrome (SIRS)
•Two of 4 criteria, 1 of which must be abnormal temperature or abnormal
leukocyte count:
1. Core temperature >38.5°C (101.3°F) or <36°C (96.8°F) (rectal, bladder, oral,
or central catheter)
2. Tachycardia: Mean heart rate >2 SD above normal for age or Unexplained
persistent elevation over 0.5-4 hr or In children <1 yr old, persistent
bradycardia over 0.5 hr (mean heart rate <10th percentile for age )
Shock

18. Cont...
3. Respiratory rate >2 SD above normal for age
4. Leukocyte count elevated or depressed for age or >10% immature
neutrophils
Shock

19. Other sepsis-scoring criteria
•The sequential organ failure assessment (SOFA) score and the abbreviated
version (qSOFA) are a newer set of criteria.
•SOFA and qSOFA help predict mortality associated with sepsis.
•Can be used as an alternative to SIRS
•Sepsis is suspected when 2 of the qSOFA criteria are met.
•The 3 criteria for the qSOFA score include:
– RR -tachypneic
– Systolic blood pressure -hypotension
– Altered mental status
Shock

20. Severe Sepsis
Sepsis plus 1 of the following:
1. Cardiovascular organ dysfunction, defined as:
• Despite >40 mL/kg of isotonic intravenous fluid in 1 hr: Hypotension <5th
percentile for age, systolic blood pressure <2SD below normal for age or
Need for vasoactive drug to maintain blood pressure
OR
• Two of the 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 or
Core-to-peripheral temperature gap: >3°C (5.4°F)
Shock

21. Cont...
2. (ARDS), bilateral infiltrates on chest radiograph, and no evidence of
left-sided heart failure.
or
•Sepsis plus ≥2 organ dysfunctions (respiratory, renal, neurologic,
hematologic, or hepatic).
Shock

22. Approach to a child with shock
• Directed history
▪ GI loss
▪ Kidney loss
▪ Bleeding
▪ Burn
▪ Decreased urine out put
• Past medical history
▪ heart disease
▪ Surgical hx
▪ steroid use
▪ medical problems
Shock

23. Physical examination
– The clinical presentation of patient with shock varies
according to the type of shock and the phase of shock
– General Appearance
•Active bleeding site, acute burn
•Change in level of consciousness
•Cardiorespiratory distress
•Well nourished or malnourished
Shock

24. Cont...
• Vital sign
– PR- tachycardia
– RR- usually tachypnea
– BP- normal or decreased. The classification
of shock may be suggested by changes in
the pulse pressure.
•Narrow PP(<30 mm Hg) Hypovolemic
and cardiogenic shock
•Wide (>40 mm Hg) distributive shock
– Temperature- febrile or hypothermia
indicating septic shock
Shock

25. Cont...
• Respiratory system
– Signs respiratory distress
– stridor or wheezing indicating anaphylaxis
• Cardiovascular system
– Pulse
– distended neck vein-suggesting heart failure
– abnormal heart sound- murmur, gallop,
Shock

26. • Gastrointestinal system
 hepatomegaly
 abnormal abdominal findings like abdominal distension, tenderness, is
consistent with bowel obstruction, perforation, or peritonitis, septic shock
• Musculoskeletal system
 Edema
• Integumentary system
 Cool extremities, warm extremities
 Prolonged capillary refill
• Nervous system
 Level of consciousness-alert or lethargic
 Muscle tone-hypotonia
Shock

27. APPROACH TO A PATIENT
• Fever
• Tachycardia
• Orthostatic hypotension
• Blood pressure –hypotension , unless compensated shock
• Respiratory rate-tachypneic
• Altered mental status
• Delayed capillary refill , decreased peripheral pulses
– Prolonged capillary refill: >3 sec except in case of warm shock
Shock

28. • Dry mucous membranes, dry axillae, poor skin turgor, and
decreased urine output.
- oliguria: urine output <0.5 mL/kg/hr
• Distal Cool extremities
• Petechiae , diffuse erythema, ecchymoses, ecthyma
gangrenosum, and peripheral gangrene.
Shock
Cont...

29. Cont...
• Early signs(compensated)
Increased heart rate
Poor systemic perfusion
• Late signs(decompensated/hypotensive)
Hypotension
week central pulses
Altered mental status
Shock

30. Cont...
• Septic Shock is unique in that hypotension and poor organ perfusion
may be present despite “good” perfusion ans is still a sign of
decompensating.
• For this reason we may get fast capillary refill, tachycardia and
bounding pulse, warm extremity.(warm shock)
Shock

31. Diagnosis
•Shock is a clinical diagnosis based on a thorough history and physical
examination
Laboratory Findings:
•CBC
•RBS
•Culture
•Lactate
•ABG
•RFT
- Serum creatinine >0.5 mg/dL/2xULN/2xbaseline
Shock

32. Cont...
•PT,PTT,INR
- INR >1.5 or aPTT >60 sec
•LFT
- Total bilirubin ≥4 mg/dL ,ALT- 2× ULN
•EKG,ECHO
•CXR
Shock

33. MANAGEMENT OF PEDIATRIC
SHOCK
Shock

34. Fundamentals of shock management
• Optimizing oxygen content of the blood
• Improving volume and distribution of cardiac output
• Reduction in oxygen demand
• Correction of metabolic derangements
Shock

35. Components of general management of
shock
• Airway and breathing (ABCs of life)
• Vascular access
• Fluid resuscitation
• Monitoring
• Lab studies
• Medical therapy
Shock

36. Hypovolemic shock
• Infusion of fluid (Normal Saline or colloid)
• Assess for adequacy of treatment
• For non-malnourished 20ml/kg fast, can be repeated if no response up to 3
to 4 times
• If needed repeat the bolus with maximum tolerated dose being 60 – 80
ml/kg with in the first 1 – 2 hr.
• For malnourished children 15ml/kg over 1 hour
• If due to hemorrhage, transfusion of packed Red Blood Cells (RBC) or whole
blood 20ml/kg over 4 hrs. , repeated as needed until Hgb level reaches
10gm/dl and the vital signs are corrected.
Shock

37. Fluid resuscitation in increments of 20 mL/kg should be titrated to
normalize
•HR (according to age-based HRs)
•Urine output (to 1 mL/kg/hr)
•Capillary refill time (to <2 sec), and
•Mental status
If shock remains refractory following 60-80 mL/kg of volume
resuscitation, vasopressor therapy
Shock

38. Cardiogenic shock
First line
• Dobutamine, 2.5-40 micrograms/kg/min IV diluted in dextrose 5%.
Never initiate Dobutamine alone in a patient with cardiogenic shock and
Systolic BP< 70
OR
• Adrenaline, I.V. infusion: Initial: 0.1-0.5 mcg/kg/minute ( 7-35 mcg/minute
in a 70 kg patient); titrate to desired response
• Norepinephrine (noradrenaline), Initial: 0.5-1 mcg/minute and titrate to
desired response; 8-30 mcg/minute is usual range. Goal: MAP>65mmhg
• Dopamine, 5-20mcg/kg/min IV diluted with dextrose 5% in Water, or in
sodium chloride solution 0.9%;
Shock

39. Distributive shock
•These patients may benefit temporarily from volume resuscitation, but
•early initiation of a vasoconstrictive agent to increase SVR is an
important element of clinical care.
•Patients with spinal cord injury and spinal shock may benefit from
either phenylephrine or vasopressin to increase SVR.
•Epinephrine is the treatment of choice for patients with anaphylaxis.
Shock

40. Anphylactic shock managment
• Control life threatening cardiopulmonary problems
• Reversal or blockage of mediators release
– Fluid bolus
– Vasopressor: epinephrine
– Antihistamines
– Corticosteroid
Shock

41. Resuscitation goals
• Mean arterial pressure > 65 mm Hg
• Urine output > 0.5 mL/kg/hour
• Central venous pressure (CVP) 8–10 mm Hg
• ScvO₂ > 70%
Shock

42. • Give o2 and establish IV line access and begin resucitation
• Consider ABG/VBG,lactate,glucose,ionized calcium,cultures, CBC
• In the first 1 hr push repeatedly 20mL/kg boluses of isotonic
crstalloid fluid to rx shock unless rales ,hepatomegaly,respiratory
distress develops
Shock

43. Additional therapies
• Correct hypoglycemia and hypocalcemia
• Administer first dose antibiotics STAT
• Consider ordering vasopressor drop and hydrocortisone
• Establish 2nd vascular line if vasoactive infusion anticipated
Shock

44. Neonates ampicillin plus cefepime and/or gentamicin
Neisseria meningitidis,Haemophilus influenzae treated empirically with a third-generation cephalosporin
(e.g., ceftriaxone, cefepime)
Resistant Streptococcus pneumoniae
MRSA
Vancomycin
Intraabdominal
process is suspected
metronidazole, clindamycin, or piperacillin-tazobactam
Nosocomial sepsis a third- or fourth-generation cephalosporin or
a penicillin with an extended
gram-negative spectrum (e.g., piperacillin-tazobactam).
Indwelling medical
device
Vancomycin
Acyclovir should be added if herpes
simplex virus suspected clinically
For selected immunocompromised patients Empirical coverage for fungal infections

45. Obstructive shock
Ductal dependent Tension pneumothorax Cardiac tamponade Pulmonary embolism
Prostaglandin E1 Needle compression pericardiocentesis thrombolytic,
anticoagulants
Expert consultation Tube thoracotomy 20ml/kg NS/RL bolus 20ml/kg NS/RL bolus
Expert consultation
Shock

46. Prognosis
• In septic shock, mortality rates are as low as 3% in
previously healthy children and 6–9% in children with
chronic illness (compared with 25–30% in adults).
• With early recognition and therapy, the mortality rate
for pediatric shock continues to improve.
Shock

47. • The risk of death involves a complex interaction of
factors, including
✓the underlying etiology,
✓ presence of chronic illness,
✓host immune response, and
✓ timing of recognition and therapy
Shock

48. References
• Nelson text book of pediatrics 21st ed
• STG guideline 4th ed
6/17/2024

49. thank you!