SHOCK

Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital

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

Pathophysiology
Delivery of Oxygen (DO2): DO2 = Cardiac output (CO) x Arterial oxygen content (CaO2) CO = Heart Rate (HR) x Stroke Volume (SV) CaO2= Hb x SaO2 x 1,39

Preload SV Blood Pressure CO HR SVR Myocard Contractility Afterload

CO = Cardiac Output SVR = Systemic Vascular resistance SV = Stroke Volume HR = Heart Rate
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Clinical Manifestation
Three phases: compensated, uncompensated, irreversible
Clinical Sign Heart rate Systolic BP Pulse volume Capillary refill Skin Respiratory rate Mental state Compensated Tachycardia + Normal Normal/reduced Normal/increased Cool,pale Tachypnoea + Mild agitation Uncompensated Tachycardia ++ Normal or falling Reduced + Increased + Cool,mottled Tachypnoea ++ Lethargic Uncooperative Irreversible Tachycardia /bradicardia Plummeting Reduced ++ Increased ++ Cold,deathly pale Sighing respiration React only to pain or unresponsive

Management

Intubation & mechanical ventilation Fluid resuscitation Vasoactive infusion

FUNCTIONAL CLASSIFICATION
Hypovolemia Cardiogenic Obstructive Distributive Septic Endocrine

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

CLINICAL MANIFESTATION: Tachycardia Skin mottling Prolonged capillary refill Cool extremities UOP Hypotensive Lethargy / comatose

THERAPY Adequate oxygenation and ventilation Rapid volume replacement reestablish circulation:
Crystalloid: 20 ml/kg shock persist Hemorrhagic: transfusion 20 ml/kg

Shock (+)

Continuous monitoring of HR, arterial BP, CVP, UOP

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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 (+)

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REFRACTORY SHOCK:
Unrecognized pneumothorax / pericardial effusion Intestinal ischemia Sepsis Myocardial dysfunction Adrenal cortical insufficiency Pulmonary hypertension

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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
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CLINICAL MANIFESTATION Tachycardia Hypotensive Diaphoretic Oliguria Acidotic Cool extremities Altered mental status Hepatomegaly Jugular venous distension Rales Peripheral edema
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THERAPY Tissue oxygen supply Tissue oxygen requirements Correct metabolic abnormalities Preload should be optimized Myocardial contractility: inotropic agent cathecholamine: norepinephrine, epinephrine, dopamine & dobutamine

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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

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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
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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

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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

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 Sepsis: SIRS + documented infection Severe sepsis: Sepsis + end organ dysfunction Septic shock: Sepsis with hypotension despite adequate fluid resuscitation

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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

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0 min 5 min

Recognize decreased mental status and perfusion. Maintain airway and establish acces according to PALS guidelines Push 20 cc/kg isotonic saline or colloid boluses up to and Over 60 cc/kg correct hypoglycemia and hypocalcemia Fluid refractory shock**

15 min

Fluid responsive*

Establish central venous access, begin dopamine or Dobutamine therapy and establish arterial monitoring Fluid refractory-dopamine/dobutamine resistant shock

Observe in PICU

Titrate epinephrine for cold shock, norepinephrine for warm shock to Normal MAP-CVP difference for age and SVCO2 saturation > 70% Catecholamine-resistant shock resistant

At risk of adrenal insufficiency ? 60 min 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 O2 Sat < 70% Add vasodilator or type III PDE inhibitor with volume loading

Low Blood Pressure Cold Shock SVC O2 Sat < 70% Titrater volume resuscitation and epinephrine Persistent Catecholamine-resistant shock

Low Blood Pressure Warm Shock SVC O2 Sat < 70% 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/m2

Refractory shock

ECMO

THANK YOU
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