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  1. 1. Tiếp cận bệnh nhi sốc
  2. 2. Definition • Pediatric shock is a condition that occurs when the delivery of oxygen and nutrients to the organs and tissues of the body is compromised.
  3. 3. Type and Severity • Type: - Hypovolemic Shock - Obstructive Shock - Distributive/Septic Shock - Cardiogenic Shock • Severity: - Compensated Shock: Normal systolic BP, decreased level of consciousness, cool extremities with delayed capillary refill, and faint or non-palpable distal pulses - Hypotensive Shock: Hypotension with signs of shock
  4. 4. Understanding Shock Shock results from a failure in one or more of the components involved in the tissue oxygen delivery process. • Sufficient cardiac output that provides enough oxygen saturated blood to meet the demands of the tissues and organs of the body. (click for full explanation) • Adequate hemoglobin concentration with sufficiently oxygen saturated hemoglobin. (click for full explanation) • Proper distribution of the blood to appropriate organs and tissues. (click for full explanation)
  5. 5. Cardiac output • CO = HR x SV. Three factors that influence stroke volume are preload, afterload, and contractility. • Inadequate preload: severe dehydration, hemorrhage, or vasodilation. • Inadequate contractility: myocarditis, drug or toxin overdose, and possibly hypoglycemia. • Increase in afterload (rarely) caused by severe pulmonary hypertension and congenital aortic abnormalities
  6. 6. • Cardiac output has a direct effect upon the progression or improvement of shock. • Cardiac output = stroke volume (preload, afterload, and contractility) x heart rate • Summary sentence: If you change heart rate, preload, afterload, or contractility, you alter cardiac output.
  7. 7. Recognition of Pediatric Shock • Tachycardia: • Increased Systemic Vascular Resistance (Vasoconstriction) — slowed capillary refill, — cool, pale, and mottled skin — weak peripheral pulses — decreased urine output • Increased Cardiac Contractility: • Blood Pressure
  8. 8. Blood pressure • In children, the compensatory mechanism of increased systemic vascular resistance can be very effective at maintaining systolic blood pressure. However, because of the increase in systemic vascular resistance (SVR), diastolic pressure is typically elevated. The increased SVR causes a narrowed pulse pressure which is the difference between the systolic and diastolic blood pressure • Blood pressure may remain normal, and a critically ill child may still have signs of shock. However, it is likely that there will be a narrowed pulse pressure.
  9. 9. Progession of shock The progression of shock is unpredictable in the pediatric population, and observing for changes in signs and symptoms can help detect shock progression.
  10. 10. Treatment of shock
  11. 11. General actions • Improve cardiac output —Fluid resuscitation —Vasopressors • Improve the level of oxygen in the blood —FiO2 100% —Blood transfusion • Decrease the body’s oxygen demand —Fever —Pain, anxiety • Normalize metabolic and electrolyte imbalances —Metabolic acidosis —Hypoglycemia —Hypocalcemia —Hyperkalemia
  12. 12. Laboratory Values for Evaluation of Shock • Lactate (Lactic Acid) • Normal arterial lactate levels are < 2 mmol/L • Complete Blood Count (CBC) • Hb: indicator of blood and/or fluid loss, help determine fluid resuscitation effects and blood transfusion • WBC • PLT: indicator of decreased PLT production and DIC • Arterial Blood Gas • Potassium • Ionized Calcium • Central venous oxygen saturation (ScvO2) • Glucose
  13. 13. Types of shock
  14. 14. Hypovolemic shock
  15. 15. Signs & Symptoms of Pediatric Hypovolemic Shock • A: Typically the Airway of the child with hypovolemic shock will not be significantly affected. • B: The patient may experience some Breathing changes and this may be recognized by a nonlabored tachypenea. • C: The most notable changes will likely be seen with circulation. These circulation changes include tachycardia, narrowing pulse pressure, possible systolic hypotension, capillary refill time > 2 seconds, cool/pale skin, weak to absent peripheral pulses, reduced urine output. • D: Disability or neurological changes include decreased level of consciousness. • E: Exposing the patient to observe the child’s skin and extremities will often reveal cool, pale, and mottled extremities.
  16. 16. Treatment of Pediatric Hypovolemic Shock • The main treatment for the critically ill child with hypovolemic shock is fluid resuscitation
  17. 17. Distributive shock • Septic Shock • Anaphylactic Shock • Neurogenic Shock
  18. 18. Septic Shock Overview • Warm Shock • Cold Shock
  19. 19. Recognition of Septic Shock • Airway: • Breathing: • increased respiratory rate (compensation for metabolic acidosis) • There may be an increased work of breathing if the patient is developing ARDS • Circulatory: • Tachycardia (earliest sign) • bounding peripheral pulses (warm shock) • flash capillary refill (warm shock) • widening pulse pressure (warm shock) • capillary refill > two seconds (cold shock) • mottled cool extremities (cold shock) • Decreased urine output (caused by poor circulatory perfusion) (less than 1 ml/kg/hr is oliguria) • narrowing pulse pressure (cold shock) • Disability: • Mental status changes occur as shock progresses. • Restlessness → agitation → anxiousness → decreased mental status (warm and cold shock) • Exposure: • Petechial rash (result of meningococcemia or DIC) • Hyperthermia (warm shock) • Warm flushed skin (warm shock) • Hypothermia (cold shock) • Cool mottled extremities (cold shock)
  20. 20. Vasoactive drugs • Fluid-Refractory “normotensive” shock • When a child has fluid-refractory shock and presents with signs of poor perfusion but has a normal blood pressure, vasoactive medications should be used to increase myocardial contractility: dopa, adre • Fluid-Refractory “warm” shock • Signs of poor perfusion and hypotension (bounding pulses, flushed skin, and flash- capillary refill) • The vasoactive medication of choice for fluid refractory “warm” shock is norepinephrine. The infusion rate should be between 0.1-2 mcg/kg/min. This should be titrated to desired effect • Fluid-Refractory “cold” shock • Signs of poor perfusion and hypotension with vasoconstriction (mottled skin, delayed capillary refill) • vasoactive medications should be used to improve blood pressure by increasing myocardial contractility with minimal vasoconstriction: EPINEPHRINE
  21. 21. Anaphylactic Shock: Management • IM epinephrine • concentration of 1:1,000 • 0.01 mg/kg • Intramuscular • Max dose 0.5 mg. • May be repeated every 5‐15 min as needed if symptoms persist.
  22. 22. Neurogenic Shock Overview • Neurogenic Shock is a type of distributive shock in which severe central nervous system trauma (i.e. spinal cord injury) causes a rapid loss in sympathetic stimulation • This loss of sympathetic tone results in massive vasodilation and a decrease in peripheral vascular resistance causing blood to pool in the venous system. • Signs & Symptoms: Children with neurogenic shock usually present with hypotension and bradycardia because of the loss of sympathetic tone. The following are signs and symptoms of neurogenic shock:
  23. 23. Cardiogenic shock • Cardiogenic shock can also occur secondary to other forms of untreated shock as a result of inadequate oxygen delivery to the myocardium.
  24. 24. Signs of cardiogenic shock • The 4 common clinical signs that distinguish cardiogenic shock are tachycardia, dyspnea, jugular vein distention, and hepatomegaly. • Increased respiratory effort is often the distinguishing characteristic that sets cardiogenic shock apart from other forms of shock.
  25. 25. Management of cardiogenic shock • Improve cardiac function • Myocardial Oxygen Demand • Last Resort: ECMO
  26. 26. Obstructive shock • Obstructive shock occurs when adequate oxygen and nutrient delivery to the organs and tissues of the body is compromised as a direct result of an obstruction to flow into or out of the heart • The most common causes of obstructive shock in children are tension pneumothorax, pulmonary embolism, and cardiac tamponade. There are also several congenital abnormalities that can cause obstructive shock. Examples include critical aortic stenosis and coarctation of the aorta.