Jackie Williams-Connolly RNJackie Williams-Connolly RNLaila Brown BN, RNLaila Brown BN, RNJaneway EmergencyJaneway Emergency

October 2013October 2013

What is Shock?

Circulatory system failure to supply oxygen and nutrients to meet cellular metabolic demands

Results from inadequate tissue perfusion

Shock is the most reversible cause of death in children!!!

Shock in Pediatrics

Types:

•Hypovolemic

•Distributive

•Cardiogenic

•Obstructive

# 1 cause of death in children worldwide

Causes• Water Loss

(diarrhea, vomiting with poor PO intake, diabetes, major burns)

• Blood Loss (obvious trauma; occult bleeding from pelvic fractures, blunt abdominal trauma, “shaken baby”)

Hypovolemic Shock:a result of blood and/or body fluid loss

Distributive Shock:A result of excessive vasodilation and the impaired distribution of blood flow

Causes:•Occurs when the blood vessels dilate, resulting in poor distribution of blood flow or volume

•The vasodilation and venodilation cause pooling of blood in the venous system

Most common forms of distributive shock are•Septic shock•Anaphylactic shock•Neurogenic shock (spinal injury)

Causes:

•Congenital heart disease

•Myocarditis (inflammation of heart muscle)

•Cardiomyopathy (an inherited or acquired abnormality of pumping function)

•Dysrhythmias

•Myocardial injury (trauma)

Cardiogenic Shock:Results from ineffective tissue perfusion caused by inadequate contraction of the

cardiac muscle

Causes:

•Because of a physical obstruction or compression of the great veins, aorta, pulmonary arteries, or the heart

•Cardiac tamponade

•Tension pneumothorax

•Massive pulmonary embolism

Obstructive Shock:Results from an inadequate circulating blood

volume

Hemodynamic definitions of shock

Initial

• Cardiac output is decreased and tissue perfusion is impaired

• decrease blood supply (oxygen) to the cells

• Anaerobic metabolism decreases energy but increases lactic acid

• Lactic acidemia (metabolic acidosis) quickly causes more cellular damage

• Minimal changes in Vital Signs

• Normal BP

ALTERED MENTAL STATUS

•Irritable, inconsolable

•Does not interact with parent

•Stares into space

•Poor response to pain

KEYS to Early Shock Recognition

ABNORMAL PERFUSION

•Decreased or bounding peripheral

pulses

•Poor capillary refill

•Decreased urine output

Compensatory• The patient in this stage of shock has very few symptoms, and

treatment can completely halt any progression

• low blood flow (perfusion) is first detected (Capillary Refill)

• Multiple systems are activated in order to maintain/restore perfusion

• Heart rate increases

•Vasoconstriction-changes in skin color & pulses

•The kidney works to retain fluid in the circulatory system

All this serves to maximize blood flow to the most important organs and systems in the body

BP is not a good indicator:

•Could still be normal

•Children can lose up to 25% of fluid volume before we see a change

• Methods of compensation begin to fail

• The systems of the body are unable to improve perfusion any longer, and the patient's symptoms reflect that fact

• Oxygen deprivation in the brain causes the patient to become confused and disoriented, while oxygen deprivation in the heart may cause chest pain

• With quick and appropriate treatment, this stage of

shock can be reversed.

Hypotensive/Decompensated

• the length of time that poor perfusion has existed begins to take a permanent toll on the body's organs and tissues

• The heart's functioning continues to spiral downward, and the kidneys usually shut down completely

• Cells in organs and tissues throughout the body are injured and dying

• Complete failure of compensatory mechanisms

• Death even in the presence of Resuscitation

Refractory/Irreversible

Blood pressure may be normal in early, compensated shock

Normal Bp = 70 + 2X age ( 1-10 yrs)

Low blood pressure does not occur until LATE shock

Tachycardia is a non-specific sign of distress

WARNING !!!

LATE SHOCK

Vital Signs:•Tachycardia•Tachypnea•Hypotension

Exam Findings:

•Agitated, confused, decreased LOC•Poor tone•Tacky mucous membranes•Cool, mottled extremities•Decreased pulses•Delayed capillary refill, >4 seconds•Late Shock is a Pre-arrest State!!

Death

• If symptoms of shock are missed

• If treatments are inadequate or delayed

• Shock progression is typically an “accelerating condition”

• It may take hours for compensated shock to progress to hypotensive shock

• Only minutes for hypotensive shock to progress to cardiopulmonary failure and cardiac arrest!

Death even in the presence of Resuscitation

Treatment of shock• ABC’S

• IV/IO access ! ( don’t waste valuable time on IV access, IO very practical in kids)

• Fluids : 20 ml/kg over 5-10 minutes (unless Cardiac involvement is suspected then 5-10 ml/kg always reassess chest sounds/CXR for signs of fluid overload)

USE N/S (preferred) or R/L (if no Renal Problems due to K)Too much fluid can cause Cerebral Edema (esp. in DKA)

• Antimicrobial coverage is essential • Steroids (2MG/KG TO MAX 100MG)• Consider inotropic and vasoactive agents

• Good History from family (SAMPLE)

Always reassess your patient, their treatments and the plan

Anti Microbial Treatment is essential to increase survival rates:

Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock

Case Study:

• 4 month old male, previously well• Parents state he has had fever, vomiting and

diarrhea for the past two days• Today, extremely fussy and refusing feeds• One wet diaper over the past 12 hours

Case Study: Physical Exam

• Toxic-appearing infant, irritable, does not console

• T-39.6 HR-206 RR-66 BP-129/109• Sat probe is not picking up well• Tacky mucous membranes• Sunken fontanel• Palpable femoral pulse, thready

peripheral pulses• Extremities cool and mottled

Case Study:

• What history is concerning?

• What exam findings are concerning?

• What stage of shock is this infant in?

• What type of shock?

• How do you start management?

Treatment:

• You place the baby on oxygen

• You are able to insert a peripheral IV

• What if you can’t get an IV? IO?

• What fluids and how much?

• Antimicrobials

Treatment & Goals:

• Reassessment

• You estimate the baby is 5 kg and give NS 100ml

rapidly

• Infant still fussy and mottled

• You give a second NS bolus of 100mL

• On reassessment, somewhat fussy, alert

• HR-180 RR-30 BP-130/100 O2sat 100% on 100%O2

• cap refill <2s

Take Home Points: Shock is the most reversible cause of death in children

BP has little to do with early shock recognition

It is NOT OK to sit on a patient who has compensated shock

Late shock is a pre-arrest state

The majority types of Shock is fluid responsive

Shock is a major cause of morbidity and mortality in

pediatric patients

Early and aggressive management leads to improved

outcomes!

Reassess, Reassess,

Questions ???