Pediatric emergencies (SHOCK & COMA) Dr Mubarak Abdelrahman Assistant Professor Jazan University

Pediatric emergencies (SHOCK & COMA) Dr Mubarak Abdelrahman Assistant Professor Jazan University

SHOCK Definition: Shock is a syndrome = inability to provide sufficient oxygenated blood to tissues. Oxygen delivery is related to: - The arterial oxygen content (oxygen saturation and hemoglobin concentration). - The cardiac output (stroke volume, heart rate, and systemic vascular resistance).

Type Classification of Shock and Common Underlying Causes Primary Circulatory Derangement Common Causes Hypovolemic Distributive Cardiogenic Decreased circulating blood volume Vasodilation venous pooling decreased preload Maldistribution of regional blood flow Decreased myocardial contractility Obstructive Mechanical obstruction to ventricular outflow Dissociative Oxygen not released from hemoglobin Methemoglobinemia

CLINICAL MANIFESTATIONS All forms of shock show evidence of insufficient tissue perfusion and oxygenation (increased heart rate, abnormal blood pressure, alterations of peripheral pulses). The etiology of shock may alter the initial presentation.

Hypovolemic Shock Clinical manifestations include : - Changes in mental status, - Tachypnea,. - Signs of dehydration (dry mucous membranes, decreased urine output) - Blood loss (pallor).

Cardiogenic Shock - The liver is usually enlarged. - Gallop rhythm. - Jugular venous distention. - Oliguria. - Peripheral edema.

Obstructive Shock The pulse pressure is narrow (pulses harder to feel). The liver is often enlarged. The jugular venous distention may be evident.

Distributive Shock In early stages, cytokine release results in vasodilatation = bounding pulses and vital organ function may be maintained (alert, rapid capillary refill; warm shock). If the etiology is sepsis: fever, lethargy, petechiae,

Septic shock Septic shock has 2 phases: - Early, or warm shock. - Late, or cold shock.

Dissociative Shock - Inability of Hemoglobin molecule to give up the oxygen to tissues. - Etiology: Carbon Monoxide poisoning, methemoglobinemia.

Management-General Goal: increase oxygen delivery and decrease oxygen demand. - For all children: A,B,C, Temperature control Correct metabolic abnormalities - Depending on suspected cause: Antibiotics Inotropes Mechanical Ventilation

Management-General Airway If not protected or unable to be maintained, intubate. Breathing Always give 100% oxygen. Saturation monitor Circulation Establish IV access rapidly = (IO after 90sec or after 3 attempts). Renal function monitor and frequent BP

Coma Definition: Coma is unresponsive state of unconsciousness, in which the patient shows no meaningful response to environmental stimuli.

Etiologies Coma is caused by dysfunction of: - the cerebral hemispheres (bilaterally), - the brainstem (herniation syndromes), or both. Local CNS causes. Systemic causes. Drugs and Toxins. Psychological problems.

Etiologies cont. Local CNS causes: Head Trauma: Epidural hematoma, subdural hematoma. Vascular: Hemorrhage, thrombosis, embolism. Epilepsy. Infection: Meningitis, Encephalitis. Brain Tumors.

Etiologies cont. Systemic causes: Metabolic disorders: Hypoglycemia, urea cycle disorders, organic acidemia. Renal disease. Hepatic failure. Severe systemic sepsis. Electrolytes disturbances. Stroke.

Glasgow Coma Scale (GCS) BEST EYE opening BEST VERBAL response BEST MOTOR response Spontaneous 4 Oriented 5 Obey commands 6 To verbal stimuli 3 Confused 4 Localize pain 5 To pain 2 Inappropriate words 3 Normal flexion (withdrawal) 4 None 1 Nonspecific sounds 2 Abnormal flexion (Decorticate) 3 None 1 Extension (Decerebrate ) 2 None 1

Modified GCS for infants BEST EYE opening BEST VERBAL response BEST MOTOR response Spontaneous 4 Coos, babbles 5 Spontaneous movements 6 To speech 3 Irritable, cries 4 Withdraws to touch 5 To pain 2 Cries to pain 3 Withdraws to pain 4 None 1 Moans to pain 2 Abnormal flexion (Decorticate) 3 None 1 Abnormal extension (Decerebrate ) 2 None 1

DIAGNOSTIC APPROACH Glucose. Na +, K +, Cl -, HCO 3, BUN, creatinine. AST, ALT, PT, PTT. Blood gases. Ammonia, lead level, pyruvate, lactate. Urinalysis, and urine amino and organic acids. CT, MRI, MRA, angiogram. CSF analysis. EEG. Blood and urine analyses for toxic substances.

Management Generally supportive until a definitive diagnosis. ABCs: Intubate if GCS is 8. Stabilize cervical spine. Supplement O₂. IV access.

Management Initiate empirical treatment if there are suggestive clinical features of: - hypoglycemia, - raised ICP, - bacterial meningitis, Glucose: Dextrose 0.25 g/kg after blood glucose is drawn and before the results back Do NOT delay