This document discusses the stages and types of shock. It begins by outlining the stages of shock as compensated, uncompensated, and irreversible. It then defines the main types of shock as hypovolemic, distributive, cardiogenic, and obstructive. For each type of shock, the document provides the etiology, clinical presentation, differentiation from other types, and general management approach. It particularly focuses on hypovolemic/hemorrhagic, cardiogenic, and septic shock, outlining their specific therapies which include fluid resuscitation, vasopressors, antibiotics, and other targeted interventions.

1. Dr/Ahmed Behairy
M.D Pediatrics
Assisstant Lecturer of Pediatrics and
Pediatric Intensive Care, Cairo University

2. Stages of Shock
 Compensated
– Vital organ function maintained, BP
remains normal.
 Uncompensated
– Microvascular perfusion becomes
marginal. Organ and cellular function
deteriorate. Hypotension develops.
 Irreversible

3.  Hypovolemic
 Hemorrhage
 Fluid loss
 Drugs
 Distributive
 Analphylactic
 Neurogenic
 Septic
Dissociative
 Heat, Carbon monoxide,
Cyanide
 Endocrine
 Cardiogenic
 Myocardial
dysfunction
 Dysrrhythmia
 Congenital heart
disease
 Obstructive
 Pneumothorax,
Cardiac Tamponade

4. Hypovolemic Shock
 Most common form of shock world-
wide
 Results in decreased circulating blood
volume, decrease in preload, decreased
stroke volume and resultant decrease in
cardiac output.
 Etiology: Hemorrhage, renal and/or GI
fluid losses, capillary leak syndromes

5. Hypovolemic Shock
 Clinically, history of vomiting/diarrhea
or trauma/blood loss
 Signs of dehydration: dry mucous
membranes, absent tears, decreased
skin turgor
 Hypotension, tachycardia without signs
of congestive heart failure

6. Hemorrhagic Shock
 Most common cause of shock in the
United States (due to trauma)
 Patients present with an obvious
history (but in child abuse history may
be misleading)
 Site of blood loss obvious or concealed
(liver, spleen, intracranial, GI, long bone
fracture)
 Hypotension, tachycardia and pallor

7. Hypovolemic/Hemorrhagic
Shock: Therapy
 Always begin with ABCs
 Replace circulating blood volume
rapidly: start with crystalloid
 Blood products as soon as available for
hemorrhagic shock (Type and Cross
with first blood draw)
 Replace ongoing fluid/blood losses &
treat the underlying cause

8. Cardiogenic Shock
Etiology:
– Dysrhythmias
– Infection (myocarditis)
– Metabolic
– Obstructive
– Drug intoxication
– Congenital heart disease
– Trauma

9. Cardiogenic Shock
Differentiation from other types of
shock:
– History
– Exam:
 Enlarged liver
 Gallop rhythm
 Murmur
 Rales
– CXR:
 Enlarged heart, pulmonary venous congestion

10. Cardiogenic Shock
Management:
– Improve cardiac output::
Correct dysrhthymias
Optimize preload
Improve contractility
Reduce afterload
– Minimize cardiac work:
Maintain normal temperature
Sedation
Intubation and mechanical ventilation
Correct anemia

11.  Inotropic support in cardiogenic shock:
 If normotensive: dobutamine (5-20
mic/kg/min), milrinone (0.25-1 mic/kg/min)
or levosimendan(0.05-0.2 mic/kg/min)
 If hypotensive: low dose adrenaline (0.05-0.3
mic/kg/min) then add one of the inodilators
mentioned above
 DON‘T FORGET: any fluid bolus in cases of
cardiogenic shock should not exceed 5 cc/kg to
avoid overoad.

12. Obstructive Shock
 Mechanical obstruction to ventricular
outflow
 Etiology: Congenital heart disease,
massive pulmonary embolism, tension
pneumothorax, cardiac tamponade
 Inadequate C.O. in the face of adequate
preload and contractility
 Treat underlying cause.

13. Distributive Shock
 Due to an abnormality in vascular tone
leading to peripheral pooling of blood with a
relative hypovolemia.
 Etiology
– Anaphylaxis
– Drug toxicity
– Neurologic injury
– Early sepsis
 Management
– Fluid
– Treat underlying cause

14. Dissociative Shock
 Inability of Hemoglobin molecule to give up
the oxygen to tissues
 Etiology:
• Carbon Monoxide poisoning,
methemoglobinemia, dyshemoglobinemias
 Tissue perfusion is adequate, but oxygen
release to tissue is abnormal
 Early recognition and treatment of the cause
is main therapy

15. SIRS/Sepsis/Septic shock
Mediator release:
exogenous & endogenous
Maldistribution
of blood flow
Cardiac
dysfunction
Imbalance of
oxygen
supply and
demand
Alterations in
metabolism

16.  High cardiac output with low systemic
vascular resistance.
 Clinical signs
 Warm extremities with bounding pulses,
tachycardia, tachypnea, confusion.
 Physiologic parameters
 widened pulse pressure, increased cardiac ouptut
and mixed venous saturation, decreased systemic
vascular resistance.
 Biochemical evidence:
 Hypocarbia, elevated lactate, hyperglycemia

17. Septic Shock: “Cold Shock”
 Low cardiac output with normal , high or low
systemic vascular resistance.
 Clinical signs
 Cyanosis, cold and clammy skin, rapid thready
pulses, shallow respirations.
 Physiologic parameters
 Decreased mixed venous sats, cardiac output and
CVP, increased SVR, thrombocytopenia, oliguria,
myocardial dysfunction, capillary leak
 Biochemical abnormalities
 Metabolic acidosis, hypoxia, coagulopathy,
hypoglycemia.

18.  Cold Shock rapidly progresses to mutiorgan
system failure or death if untreated
 Multi-Organ System Failure: Coma, ARDS,
CHF, Renal Failure, Ileus or GI hemorrhage,
DIC
 More organ systems involved, worse the
prognosis
 Therapy: ABCs, fluid
 Appropriate antibiotics, treatment of underlying
cause

19. A.Initial Resuscitation:
 High flow oxygen.
 Obtaining IV or IO access.
 Correct hypoglycemia, hypocalcemia.

20.  Initial therapeutic end points of resuscitation
of septic shock:
1. Capillary refill time of ≤2 seconds.
2. Normal blood pressure for age.
3. Normal pulses with no differential between peripheral
and central pulses.
4. Warm extremities.
5. Urine output >1 mL/kg/hr.
6. Normal mental status.
7. Scvo2 saturation ≥70%.
8. Cardiac index between 3.3 and 6.0 L/min/m2 should
be targeted thereafter (grade 2C)

21. B. Antibiotics and Source Control:
 All children with septic shock should receive coverage
for methicillin-resistant Staphylococcus aureus
(MRSA).
 Coverage for enteric organisms should be added
whenever clinical features suggest genitourinary (GU)
and/or gastrointestinal (GI) sources.
 Treatment for Pseudomonas species should be
included for children who are immunosuppressed or at
risk for infection with these organisms (ie, those with
cystic fibrosis).

22.  Listeria monocytogenes and herpes simplex virus are
important pathogens in neonates≤ 28 days of age.
 When treating empirically, antibiotics which can be
given by rapid intravenous bolus (eg, beta-lactam
agents or cephalosporins) should be administered first
followed by infusions of antibiotics, such as
vancomycin, that must be delivered more slowly.
 Ongoing antimicrobial therapy should be modified
based upon culture results, including antimicrobial
susceptibility and the patient's clinical course.

23. C. Fluid Resuscitation:
 isotonic crystalloids or albumin with boluses of
up to 20 mL/kg crystalloids (or albumin
equivalent) over 5–10 minutes, titrated to
reversing hypotension, increasing urine output,
and attaining normal capillary refill, peripheral
pulses, and level of consciousness without
inducing hepatomegaly or rales.

24.  If hepatomegaly or rales exist then inotropic
support should be implemented, not fluid
resuscitation. In non-hypotensive children with
severe hemolytic anemia (severe malaria or
sickle cell crises) blood transfusion is
considered superior to crystalloid or albumin
bolusing.

25. D. Inotropes/Vasopressors/Vasodilators:
 Children with severe sepsis can present with
low cardiac output and high systemic vascular
resistance (cold septic shock), high cardiac
output and low systemic vascular resistance
(warm septic shock), or low cardiac output
and low systemic vascular resistance shock.

26.  A child may move from one hemodynamic
state to another, Vasopressor or inotrope
therapy should be used according to the
hemodynamic state.
 Dopamine refractory shock may reverse with
epinephrine if cold or norepinephrine infusion
if warm.

27.  In the case of extremely low systemic vascular
resistance despite the use of norepinephrine,
the use of vasopressin and terlipressin has been
described in a number of case reports, yet
evidence to support this in pediatric sepsis, as
well as safety data, are still lacking.
 When vasopressors are used for refractory
hypotension, the addition of inotropes is
commonly needed to maintain adequate
cardiac output.

28. E. Corticosteroids:
 Timely hydrocortisone therapy in children with
fluid refractory, catecholamine resistant shock
and suspected or proven absolute (classic)
adrenal insufficiency.

29. F. Blood Products and Plasma Therapies:
 In cases of low superior vena cava oxygen
saturation (< 70%), maintain hemoglobin
levels of 10 g/dL.
 After stabilization and recovery from shock
and hypoxemia then a lower target > 7.0
g/dL can be considered reasonable.

30.  Administer platelet prophylactically when counts
are <10,000/mm3 in the absence of apparent
bleeding.
 We suggest prophylactic platelet transfusion when
counts are < 20,000/mm3 if the patient has a
significant risk of bleeding. Higher platelet counts
(≥50,000/mm3) are advised for active bleeding,
surgery, or invasive procedures.

31.  Use plasma therapies in children to correct
sepsis-induced thrombotic purpura disorders,
including progressive disseminated
intravascular coagulation, secondary
thrombotic microangiopathy, and thrombotic
thrombocytopenic purpura.

32. G.Mechanical Ventilation:
 Lung-protective strategies during mechanical
ventilation.

33. H. Glycemic Control:
 Control hyperglycemia using a similar target as
in adults ≤ 180 mg/dL. Glucose infusion
should accompany insulin therapy in
newborns and children.

34. I.Diuretics and Renal Replacement Therapy:
 Use diuretics to reverse fluid overload when
shock has resolved, and if unsuccessful then
continuous venovenous hemofiltration (CVVH)
or intermittent dialysis is suggested to prevent
> 10% total body weight fluid overload.

35. Algorism of management of septic
shock

37. Wrap up

38.  Any case with shock not improving with fluid
boluses, you should suspect:
1. Cardiogenic shock
2. Obstructive shock
3. Septic shock

39.  or 




Septic: Late


 Or 


Septic: Early
 Or 
 Or 
 Or 


Distributive


 Or 


Obstructive


 Or 


Cardiogenic


 Or 


Hypovolemic
CVP
Wedge
MAP
SVR
CO

41. Thank you