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shock
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SHOCKEmergency pediatric – PICU division
Pediatric Department
Medical Faculty, University of Sumatera Utara – H. Adam Malik Hospital
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Definition
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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
PathophysiologyPathophysiology
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
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CO = Cardiac OutputSVR = Systemic Vascular resistanceSV = Stroke VolumeHR = Heart Rate
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Clinical Manifestation
Clinical Sign Compensated Uncompensated Irreversible
Heart rateSystolic BPPulse volumeCapillary refillSkinRespiratory rateMental state
Tachycardia +NormalNormal/reducedNormal/increasedCool,paleTachypnoea +Mild agitation
Tachycardia ++Normal or fallingReduced +Increased +Cool,mottledTachypnoea ++LethargicUncooperative
Tachycardia /bradicardiaPlummeting Reduced ++Increased ++Cold,deathly paleSighing respirationReact only to pain orunresponsive
Three phases: compensated, uncompensated, irreversible
Management
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• Intubation & mechanical ventilation• Fluid resuscitation• Vasoactive infusion
• Intubation & mechanical ventilation• Fluid resuscitation• Vasoactive infusion
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FUNCTIONAL CLASSIFICATION
• Hypovolemia• Cardiogenic• Obstructive• Distributive• Septic• Endocrine
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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
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CLINICAL MANIFESTATION:• Tachycardia• Skin mottling• Prolonged capillary refill• Cool extremities• ↓ UOP• Hypotensive• Lethargy / comatose
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THERAPY• Adequate oxygenation and ventilation• Rapid volume replacement reestablish circulation:
– Crystalloid: 20 ml/kg shock persist 20 ml/kg– Hemorrhagic: transfusion
Continuous monitoring of HR, arterial BP, CVP, UOP Continuous monitoring of HR, arterial BP, CVP, UOP
Shock (+)Shock (+)
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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
ECMORefractory shockStart 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
Persistent Catecholamine-resistant shock
Add vasodilator or type III PDE inhibitor with volume loading
Normal Blood Pressure Cold ShockSVC O2 Sat < 70%
Low Blood Pressure Cold ShockSVC O2 Sat < 70%
Titrater volume resuscitationand epinephrine
Low Blood Pressure Warm ShockSVC O2 Sat < 70%
Titrater volume and norepinephrine
60 min Draw baseline cortisol level Then give hydrocortisone
Draw baseline cortisol level or perform ACTH stim test. Do not give hydrocortisone
Not at risk ?
Catecholamine-resistant shock resistant
Observe in PICUTitrate epinephrine for cold shock, norepinephrine for warm shock to
Normal MAP-CVP difference for age and SVCO2 saturation > 70%
Establish central venous access, begin dopamine orDobutamine therapy and establish arterial monitoring
Push 20 cc/kg isotonic saline or colloid boluses up to and Over 60 cc/kg correct hypoglycemia and hypocalcemia
Fluid responsive*
15 min
Recognize decreased mental status and perfusion.Maintain airway and establish acces according to PALS guidelines
0 min5 min
At risk of adrenal insufficiency ?
Fluid refractory-dopamine/dobutamine resistant shock
Fluid refractory shock**
THANK YOU
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