Pediatrics focused management of all types of shock

1. Moderator- Dr. Yasin (Assistant Professor of Pediatrics)
Prepared by- Dr. Michael S
Seminar on
Management of
Shock

2. Outline
• Definition
• Physiologic response
• Pathophysiologic change
• Classification
• Stages
• Clinical features and diagnosis
• Management of shock
• Prognosis

3. Definition
• Shock is a physiologic state characterized by a significant reduction of
systemic tissue perfusion resulting in decreased oxygen delivery to the
tissues
• Creates an imbalance between oxygen delivery and oxygen
consumption
• Prolonged oxygen deprivation leads to cellular hypoxia and
derangement of critical biochemical processes at the cellular level
which can progress to the systemic level

4. • Shock based on the type in general has a high mortality rate
ranging from 20-80%
• Better mortality rate of shock in children compared to adults
• The early phase of these shocks is reversible and the aim of
treatment is to prevent irreversible cellular damage and
restore normal function of the circulatory system

5. Normal tissue perfusion
• Determined by Mean Arterial Pressure (MAP)
MAP = Cardiac Output x Systemic Vascular Resistance
HR Stroke Volume
Contractility
Afterload
Preload

6. Physiological response
• Activation of sympathetic nervous system:- release of catecholamine from
adrenal gland which lead to increase CO & SVR
• Activation of Renin-Angiotensin system :-which allow vasoconstriction &
retention of fluid and salt with concentration of urine

8. Types of Shock
I. Hypovolemic
II. Cardiogenic
III. Obstructive
IV. Distributive

9. Hypovolemic Shock
- Decreased Intravascular volume (Preload) with a properly
functioning heart leading to a decreased Stroke Volume
Causes (either loss of blood or loss of body fluid)
- Hemorrhage - trauma, GI bleed, AAA rupture
- Loss of fluid - burns, GI losses, dehydration, third spacing (e.g.
pancreatitis, bowel obstruction) or DKA

10. Classification of pediatric hemorrhage shock

11. Cardiogenic Shock
- Shock where the heart is unable to pump adequate amount of blood that will
lead to inadequate perfusion of organ and tissue
Causes
Decreased Contractility
MI (e.g. kawasaki’s disease, anomalous origin of the left coronary artery),
myocarditis, cardiomyopathy or Post resuscitation syndrome following
cardiac arrest
Mechanical Dysfunction
Papillary muscle rupture post-MI, Severe Aortic Stenosis or Rupture of
ventricular aneurysms
Arrhythmia
Heart block, VT, SVT or atrial fibrillation
Cardiotoxic drugs
B-blocker & Calcium channel blocker OD

12. Obstructive Shock
Shock in a patient with a properly working heart with obstruction to
the return or outflow tract of the heart
Causes
Outflow obstructions
• Massive pulmonary embolism
• Aortic dissection
• Constrictive pericarditis
• Cardiac tamponade
• Tension pneumothorax
Venous return obstruction
• Vena cava syndrome - eg.
neoplasms, granulomatous
disease

13. Distributive Shock
Shock where heart functions properly but the preload is severely decreased
secondary to peripheral vasodilation (loss of vessel tone)
Inflammatory loss of vessel tone
Septic shock most common etiology of distributive shock among children
Anaphylactic shock
Post resuscitation syndrome following cardiac arrest
Decreased sympathetic nervous system function
Neurogenic - cervical or upper thoracic spinal injuries
Toxins
Drug overdose (a1 antagonists)

14. Warm shock Cold shock
With too little resistance to blood flow too much resistance to blood flow
hypotensive hypotensive
flash capillary refill delayed capillary refill
bounding pulses poor pulses
Warm extremities mottled and cool extremities
Septic Shock

15. Sepsis: SIRS plus a suspected or proven infection.
SIRS :
Two of 4 criteria
1. Core T >38.5°C or <36°C
2. Mean PR >2 SD .
3. RR >2 SD or need for mechanical ventilation.
4. WBC count ↑ed or ↓ed or >10% immature neutrophils.
The clinical spectrum of sepsis

16. Severe sepsis: Sepsis plus 1 of the following:
1. CV OD :
Despite >60 mL/kg of isotonic IV fluid in 1 hr:
- HoTN or
-Need for vasoactive drug or
2 of the following:
-metabolic acidosis: base deficit >5 mEq/L.
-↑ed arterial lactate: >2 times.
-Oliguria: UOP <0.5 mL/kg/hr.
- Prolonged capillary refill. >5 sec
-Core to peripheral T gap >3°C.
Septic shock
Sepsis plus cardiovascular organ dysfunction

17. - Sepsis defined by the 2017 American guideline for
surviving sepsis as
Suspected or proven infection
+
Acute increase of > 2 SOFA (Sequential
. Organ Failure Assessment) score points

20. Type of Shock Problem Problem results in Body Compensation
Hypovolemic Heart pumps well, but not
enough blood volume to
pump
↓CO
↓Preload
↑SVR
Cardiogenic Heart fails to pump blood
out
↓CO
↓Contractility
(depending on the cause)
↑SVR
Obstructive Heart pumps well, but the
outflow is obstructed
↓CO
↓Preload or
↑Afterload
(depending on the cause)
↑SVR
Distributive Heart pumps well, but there
is peripheral vasodilation
↓SVR
↓Pre load
↑CO

21. Stages of Shock (Despite the type of shock)
Progression will depend on:
- Patient (age, comorbidities,Immunity)
- Cause
- Intervention
Insult
Preshock
(Compensation)
Shock
(Compensation failed)
End organ
Damage
Death

22. 12/4/2023 22

23. 12/4/2023 23
Shock Assessment
Compensated Decompensate
Pulse Tachycardia Marked tachycardia;
can progress to
bradycardia
Skin White, cool, moist White, “waxy”, cold,
marked diaphoresis
Blood Pressure Normal range Lowered
LOC Unaltered Ranging from disoriented to
coma

24. Diagnosis Based on History, Physical Examination and Investigations
On History
- Anxiety
- Agitation
- Confusion, delirium & coma
- Fever
- Diarrhea, vomiting or loss of appetite
- Polyuria
- Hemorrhage
- Chest or epigastric pain
- Palpitation
- Trauma to the back
- History of drug use

25. On PE
-Tachycardiya HR > 2 SD
With fast feeble thready distal pulses
Rhythm irregularity
Few exceptions are
- Patient with neurogenic shock
- Bradycardic causes of shock like a heart block

26. - Tachypnea RR> 2 SD
which will be shallow, irregular and labored
- Blood pressure
In pre-shock stage it will be normal
Systolic < 90 mmHg OR MAP < 65 mmHg

27. -HEENT- Dry tongue and buccal mucosa
-Respiratory System
Cyanosis, asymmetric chest movement, use of accessory muscles
Tenderness, shifted trachea, altered tactile fremitus
Decreased or absent breath sound

28. - Cardiovascular System
Diminished peripheral pulses
Distended neck veins with elevated JVP
Quiet precordium (MI), shifted AI (cardiomyopathy)
Shifted PMI (cardiomyopathy)
Distant heart sound (Tamponade), Murmurs (Post MI, aortic
. stenosis)

29. -Integumentary
Cold & clammy (Cardiogenic, Obstructive & Hemorrhagic)
Warm (Distributive shock)
Dry Axilla
- Low Urine output of <0.5 ml/kg/hr

30. lethargy/unconscious + Cold hands with :
- capillary refill > 3 sec. and
- weak, fast or absent pulse.

31. Management
- Shock management begins with ABC of life
- Airway should be kept patent and protections should be applied if the
patient can’t protect the airway
- Intubation if
Unable to oxygenate
Unable to maintain airway
To decrease work of breathing (which increases O2 consumption
by 50-100% and decrease cerebral blood flow by 50%)

32. Breathing
- Assessed for causes of hypovolemic shock (massive hemothorax), obstructive
shock (cardiac tamponade, tension pneumothorax)
- Patient put on oxygen
Circulation
- Assessed for active bleeding or fluid loss
- Central or peripheral IV access or IO access
- Take blood samples for emergency lab test
- Keep the child warm
- Management starts with Fluid resuscitation but following steps depend on type of
shock

33. 5 – 10 minutes
• Push 20ml/kg isotonic crystalloid or colloid up to & over 60ml/kg until perfusion
improves or unless rales or hepatomegaly develop.
• Correct hypoglycemia and hypocalcemia
Fluid responsive shock
Observe PICU
Fluid refractory
FLUID MANAGEMENT

34. Pharmacologic management
Establish central venous pressure & arterial monitoring
Cold shock
Start dopamine 10-
20 u/kg/min
Warm shock
Rx – titrate
norepinephrine
Start 0.1 – 2u/kg/min
Dopamine responsive
Observe PICU
Dopamine resistant
Rx – titrate epinephrine
Start 0.1– 1u/kg/min

35. Catecholamine responsive
Observe in PICU
60 minute
•Catecholamine unresponsive
•At risk for adrenal insufficiency.
Eg=chronic steroid use or history of
adrenal suppression).
•
YES NO
•Titrate volume &
Norepinephrine
•Low dose vasopressin
Observe PICU

36. 36
YES
Hydrocortisone 50mg/kg/d
Low BP, cold shock
SVC O2 sat <70%
Titrate volume &
Epinephrine
Consider
Norepinephrine
Add Dobutamine,
milronone or
levosimendan
Normal BP, cold shock
SVC O2 sat <70%
Add vasodilator OR
Type III
phosphodiestrase
Inhibitor + volume
Low BP, warm shock
SVC O2 sat <70%
Titrate volume &
Norepinephrine
Consider vasopressin or
angiotensin
Consider low dose
epinephrine

37. If shock still not reversed
Persistent catecholamine resistant shock
Rule out and correct pericardial effusion, pneumothorax and
intraabdominal pressure >12 mm Hg
Goal C.I 3.3 to 6.0 L/min/m2
If shock still not reversed
ECMO

38. The ‘FEAST’ trial

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40. Resuscitation goals include
• Capillary refill <2 sec,
• Normal pulses with no differential between central and peripheral pulses,
• Warm extremities,
• Urine output of >1 mL/kg/hr,
• Normal mental status, and
• Normal blood pressure for age
• ScvO2 saturation ≥70% and cardiac index between 3.3 and 6.0 L/min/m2.

41. PROGNOSIS
The mortality rate for septic shock depends on
• The underlying etiology,
• Presence of chronic illness,
• Host immune response,
• Timing of recognition and therapy.
• Note pediatric patients who have undergone bone marrow transplantation
have an increased rate of mortality compared to other patients with septic
shock.
• Mortality rates = 10%.

42. Shock follow up chart
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Date Time BP PR RR Temp O2 Sat Mucosa Skin
pinch
Liver
size
Urine
output
Cap
refill
Crepta
tions
Weight

43. REFERENCEs:
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• NELSON TEXTBOOK OF PEDIATRICS 20TH EDITION.
• UptoDate 21.2
• Sepsis Surviving Campaign 2017 guideline
• Management of Hypovolemic shock
(www.eMedicine.com)

44. Thank You!