SHOCK Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital 1
Definition Shock is an acute, complex state of circulatory dysfunction that results in failure to deliver sufficient amounts of oxygen and other nutrients to meet tissue metabolic demands 2
Pathophysiology Delivery of Oxygen (DO 2 ): DO 2 = Cardiac output (CO) x Arterial oxygen content (CaO 2 ) CO = Heart Rate (HR) x Stroke Volume (SV) CaO 2 = Hb x SaO 2 x 1,39 3
Preload Blood Pressure CO SVR SV HR Myocard Contractility Afterload CO = Cardiac Output SVR = Systemic Vascular resistance SV = Stroke Volume HR = Heart Rate 4
Clinical Manifestation Three phases: compensated, uncompensated, irreversible Clinical Sign Compensated Uncompensated Irreversible Heart rate Systolic BP Pulse volume Capillary refill Skin Respiratory rate Mental state Tachycardia + Normal Normal/reduced Normal/increased Cool,pale Tachypnoea + Mild agitation Tachycardia ++ Normal or falling Reduced + Increased + Cool,mottled Tachypnoea ++ Lethargic Uncooperative Tachycardia /bradicardia Plummeting Reduced ++ Increased ++ Cold,deathly pale Sighing respiration React only to pain or unresponsive 5
Management Intubation & mechanical ventilation Fluid resuscitation Vasoactive infusion 6
FUNCTIONAL CLASSIFICATION Hypovolemia Cardiogenic Obstructive Distributive Septic Endocrine 7
HYPOVOLEMIC SHOCK A decrease in intra vascular blood volume to such an extent that effective tissue perfusion can not be maintain Most common cause of shock in infants & children Etiology: Hemorrhage Plasma loss Fluid & electrolyte loss Hypovolemia preload SV CO 8
CLINICAL MANIFESTATION: Tachycardia Skin mottling Prolonged capillary refill Cool extremities UOP Hypotensive Lethargy / comatose 9
THERAPY Adequate oxygenation and ventilation Rapid volume replacement reestablish circulation: Crystalloid: 20 ml/kg shock persist 20 ml/kg Hemorrhagic: transfusion Shock (+) Continuous monitoring of HR, arterial BP, CVP, UOP 10
CVP: < 10 mmhg fluid infusion until preload is reach >10 mmhg indication: flow-direct thermo dilution pulmonary artery catheter and/or echocardiogram Ventricular filling pressure rises without evidence of improvement in cardiovascular performance Discontinue fluid resuscitation Inotropic agent (+) 11
REFRACTORY SHOCK: Unrecognized pneumothorax / pericardial effusion Intestinal ischemia Sepsis Myocardial dysfunction Adrenal cortical insufficiency Pulmonary hypertension 12
CARDIOGENIC SHOCK The pathophysiologic state in which abnormality of cardiac function is responsible for the failure of the cardiovascular system to meet the metabolic needs of tissue Depressed CO Etiology: Heart rate abnormalities, Cardiomyopathies/carditis, Congenital heart disease, Trauma Myocardial dysfunction is frequently a late manifestation of shock of any etiology 13
CLINICAL MANIFESTATION Tachycardia Hypotensive Diaphoretic Oliguria Acidotic Cool extremities Altered mental status Hepatomegaly Jugular venous distension Rales Peripheral edema 14
THERAPY Tissue oxygen supply Tissue oxygen requirements Correct metabolic abnormalities Preload should be optimized Myocardial contractility: inotropic agent cathecholamine: norepinephrine, epinephrine, dopamine & dobutamine 15
OBSTRUCTIVE SHOCK Caused by inability to produce adequate CO despite normal intravascular volume & myocardial function Causative factor: Acute pericardial tamponade Tension pneumothorax Pulmonary / systemic hypertension Congenital / acquired outflow obstruction 16
CARDIAC TAMPONADE Hemodinamically significant cardiac compression accumulation pericardial contents that evoke & defeat compensatory mechanism Physical examination: Pulsus paradoxus Narrowed pulse pressure Pericardial rub Jugular venous distension Definitive treatment: removed pericardial fluid or air surgical drainage / pericardiocentesis Medical management: Blood volume expansion maintain venoarterial gradients Inotropic agent 17
DISTRIBUTIVE SHOCK Results from maldistribution of blood flow to the tissue May be seen with anaphylaxis, spinal / epidural anesthesia, disruption of spinal cord, inappropriate administration vasodilatory medication Treatment: Reversal underlying etiology Vigorous fluid administration Vasopressor infusion 18
SEPTIC SHOCK Contains many elements of the other types of shock discussed previously (hypovolemic, cardiogenic, and distributive shock) SIRS (Systemic Inflammatory Response Syndrome): non specific inflammatory response Modified criteria for SIRS: Temp. >38,5 C or < 36 C Tachycardia Tachypnea WBC / or >10% immature neutrophils 19
Sepsis: SIRS + documented infection Severe sepsis: Sepsis + end organ dysfunction Septic shock: Sepsis with hypotension despite adequate fluid resuscitation 20
MANAGEMENT: Early recognition Antibiotics appropriate with microbiological examination Initial fluid resuscitation 20 ml/kg boluses over 5-10 minutes up to 40-60 ml/kg in the first hour Inotropic / vasopressor refractory to fluids Mechanical ventilation refractory shock Hydrocortisone Glycemic control Blood transfusion 21
0 min 5 min Recognize decreased mental status and perfusion. Maintain airway and establish acces according to PALS guidelines 15 min Fluid responsive* Push 20 cc/kg isotonic saline or colloid boluses up to and Over 60 cc/kg correct hypoglycemia and hypocalcemia Fluid refractory shock** Establish central venous access, begin dopamine or Dobutamine therapy and establish arterial monitoring Observe in PICU Fluid refractory-dopamine/dobutamine resistant shock Titrate epinephrine for cold shock, norepinephrine for warm shock to Normal MAP-CVP difference for age and SVCO 2 saturation > 70% Catecholamine-resistant shock resistant 60 min At risk of adrenal insufficiency? Draw baseline cortisol level Then give hydrocortisone Not at risk? Draw baseline cortisol level or perform ACTH stim test. Do not give hydrocortisone Normal Blood Pressure Cold Shock SVC O 2 Sat < 70% Low Blood Pressure Cold Shock SVC O 2 Sat < 70% Low Blood Pressure Warm Shock SVC O 2 Sat < 70% Add vasodilator or type III PDE inhibitor with volume loading Titrater volume resuscitation and epinephrine Persistent Catecholamine-resistant shock Titrater volume and norepinephrine Start cardiac output measurement and direct fluid, inotrope, vasopressor, vasosilator, and hormonal therapies to attain normal MAP-CBP and CI > 3.3 and < 6.0 L/min/m 2 Refractory shock ECMO
THANK YOU 23