Shock Resident Lecture

8/9/2019 Shock Resident Lecture

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PEDIATRICPEDIATRIC

SHOCKSHOCK20122012


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SHOCKSHOCK

Shock is a syndrome that resultsShock is a syndrome that results

from inadequate oxygen delivery tofrom inadequate oxygen delivery to

meet metabolic demandsmeet metabolic demands

Sequelae of shock are metabolicSequelae of shock are metabolic

acidosis, organ dysfunction andacidosis, organ dysfunction and

deathdeath


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OXY!"S#$$%Y

OXY!"&!'("&

S)O*+OX!" S#$$%Y -(.%S /O '!!/ OXY!"&!'("&


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OY!"&!%.!Y

*(&.(* O#/$#/ X (/!.(% OXY!" *O"/!"/

*ardiacOutut

(rterial oxygen content

)eart rate Stroke olume

$reload(fter load*ontractility

)emoglobinOxygen Saturation$artial ressure of oxygen dissolvelasma


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Factors afecting OxygenFactors afecting Oxygen

deliverydelivery Oxygenation(a gradient, &$, acidOxygenation(a gradient, &$, acid

base balance, /em, :lockersbase balance, /em, :lockers

Stroke volumeentricularStroke volumeentricularcomliance, *$, venous tone,comliance, *$, venous tone,

autonomic tone, metabolic milieu,autonomic tone, metabolic milieu,

afterload, conduction systemafterload, conduction system


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Types o S!oc"Types o S!oc"

)yovolemic )emorrhage, serum or lasma)yovolemic )emorrhage, serum or lasmalossloss

&istributive(nahylactic, "eurogenic, setic&istributive(nahylactic, "eurogenic, setic

*ardiogenic 'yocardial, dysrrythmia,*ardiogenic 'yocardial, dysrrythmia,*)&8duct deendant9*)&8duct deendant9 Obstructive$neumo, tamonade, dissectionObstructive$neumo, tamonade, dissection &issociative)eat, *O, cyanide, endocrine&issociative)eat, *O, cyanide, endocrine

; has )yovolemic shock secondary to; has )yovolemic shock secondary to)emorrhage)emorrhage


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Case #Case #

< year old girl ; =ith a history of variceal bleed< year old girl ; =ith a history of variceal bleedresents =ith ne= onset bleed4 O>!resonsive,resents =ith ne= onset bleed4 O>!resonsive,)15?, 5@, :$@@>A0, SatsA0, Sats26>@0>12>64 )b642C40@>26>@0>12>64 )b642

Dhat tye of shock is thisEDhat tye of shock is thisE)yovolemic Shock)yovolemic Shock Dhat is the very Frst thing you =ould like to doDhat is the very Frst thing you =ould like to do

for this atientEfor this atientE

OxygenOxygen .s this comensated or uncomensated shock.s this comensated or uncomensated shock

ho= does the body comensateEho= does the body comensateE

*omensated*omensated


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Stages o S!oc"Stages o S!oc"

*omensated ital organ function*omensated ital organ functionmaintained, normal :$maintained, normal :$

#ncomensated'arginal microvascular#ncomensated'arginal microvascular

erfusion4Organ and cellular functionerfusion4Organ and cellular functiondeteriorate4 )yotension develos4deteriorate4 )yotension develos4

.rreversible.rreversible

; has comensated shock because her; has comensated shock because herblood ressure is normalblood ressure is normal


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Co$pensatoryCo$pensatory

%ec!anis$s%ec!anis$s :arorecetors.n aortic arch and:arorecetors.n aortic arch and

carotid sinus, lo= '($ causecarotid sinus, lo= '($ cause

vasoconstriction, increases :$, *Ovasoconstriction, increases :$, *O

and )and )

*hemorecetors esond to cellular*hemorecetors esond to cellular

acidosis, results in vasoconstrictionacidosis, results in vasoconstriction

and resiratory stimulationand resiratory stimulation


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Co$pensatoryCo$pensatory

%ec!anis$s%ec!anis$s enin (ngiotensin &ecreased renalenin (ngiotensin &ecreased renal

erfusion leads to angiotensinerfusion leads to angiotensin

causing vasoconstriction andcausing vasoconstriction and

aldosterone causing salt and =ateraldosterone causing salt and =aterretentionsretentions

)umoral esonses*atecholamines)umoral esonses*atecholamines

(utotransfusioneabsortion of(utotransfusioneabsortion of

interstitial Guidinterstitial Guid


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R&'s Clinical presentationR&'s Clinical presentation

&iagnosis is based on exam focused on tissue&iagnosis is based on exam focused on tissueerfusionerfusion

"eurological-luctuating mental status"eurological-luctuating mental status Skin and extremities*ool, allor, mottling,Skin and extremities*ool, allor, mottling,

cyanosis, oor ca reFll, =eak ulses, =eakcyanosis, oor ca reFll, =eak ulses, =eakmuscle tonemuscle tone

*ardioulmonary)yernea, tachycardia*ardioulmonary)yernea, tachycardia enalScant, concentrated urineenalScant, concentrated urine

(bHect hyotension is a late and remorbid(bHect hyotension is a late and remorbidsign8 and is the Gag for uncomensated shock9sign8 and is the Gag for uncomensated shock9


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Hypovole$ic s!oc"Hypovole$ic s!oc"

*ommonest cause =orld=ide*ommonest cause =orld=ide

&ecreased blood volume, decreased&ecreased blood volume, decreased

reload, decreased stroke volumereload, decreased stroke volume

Signs of dehydrationtears, mucousSigns of dehydrationtears, mucous

membranes, skin tugormembranes, skin tugor

Site of Guid loss may be obvious orSite of Guid loss may be obvious orconcealed8liver, sleen, intracranial,concealed8liver, sleen, intracranial,

.9.9


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Oxygen()!at aOxygen()!at a

diference*diference*(rt Oxygen content3 )b x Sa02 x 1456(rt Oxygen content3 )b x Sa02 x 1456

7804005 x $a0297804005 x $a029

$a02 on 100B is arox A?0$a02 on 100B is arox A?0

$a02 on room air is arox 100$a02 on room air is arox 100

.f your )b is 1? this diIerence in $aO2.f your )b is 1? this diIerence in $aO2

does not make much diIerence if yourdoes not make much diIerence if your

)b is ? it makes all the diIerenceJ)b is ? it makes all the diIerenceJ


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R&'s %anage$entR&'s %anage$ent

.ncrease oxygen delivery, decrease oxygen.ncrease oxygen delivery, decrease oxygen

demanddemand

OxygenOxygen

-luid-luid :lood:lood

/emerature control/emerature control

*orrect metabolic abnormalities*orrect metabolic abnormalities .notroe if needed.notroe if needed


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+a,s+a,s

(:(: :lood sugar:lood sugar

!lectrolytes!lectrolytes

*:**:* $/>$//>-ibrinogen$/>$//>-ibrinogen

/ye and *ross/ye and *ross *ultures*ultures .maging.maging


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-ol.$e expansion-ol.$e expansion

OtimiKe ;Ls reload =ith "S or %OtimiKe ;Ls reload =ith "S or %

1020cc>kg q 210min4 ; is given 21020cc>kg q 210min4 ; is given 2

boluses4boluses4

; is given 2 units of blood4 )er; is given 2 units of blood4 )er

heart rate stabiliKes at @A4 :$heart rate stabiliKes at @A4 :$

112>@04112>@04

; is deemed stable and gets; is deemed stable and gets

sclerotheraysclerotheray


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R& At EndoscopyR& At Endoscopy


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Case /Case /

/" is a ? year old girl =ith a history of #./" is a ? year old girl =ith a history of #.symtoms 2 =eeks ago resents =ithsymtoms 2 =eeks ago resents =ithdecreased eIort tolerance, tachynea 4 O>!decreased eIort tolerance, tachynea 4 O>!)1l rales, no heart murmuron exam but a gallo is heard4on exam but a gallo is heard4

Dhat tye of shock is thisEDhat tye of shock is thisE

#ncomensated cardiogenic shock#ncomensated cardiogenic shock Dhat is the diagnosisE )o= do you manageDhat is the diagnosisE )o= do you manage

this atientEthis atientE

'yocarditis'yocarditis


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Diferentiating CardiogenicDiferentiating Cardiogenic

S!oc"S!oc" )istory)istory

$!enlarged liver, gallo, murmur,$!enlarged liver, gallo, murmur,

ralesrales

*hest X ray!nlarged heart,*hest X ray!nlarged heart,

ulmonary venous congestionulmonary venous congestion


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%yocarditis%yocarditis


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OY!"&!%.!Y

*(&.(* O#/$#/ X (/!.(% OXY!" *O"/!"/

*ardiacOutut

(rterial oxygen content

)eart rate Stroke olume

$reload(fter load*ontractility

)emoglobinOxygen Saturation$artial ressure of oxygen dissolvelasma


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%anaging T0%anaging T0

.ncreasing Oxygen suly.ncreasing Oxygen suly

Sulemental OxygenSulemental Oxygen

.mroving myocardial oututaltering.mroving myocardial oututaltering

reload, after load and contractilityreload, after load and contractility*orrect (nemia:lood*orrect (nemia:lood &ecreasing oxygen demand&ecreasing oxygen demand

*ontrol temerature*ontrol temerature

SedationSedation

educe myocardial =ork and thus oxygeneduce myocardial =ork and thus oxygenconsumtionconsumtion


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Fl.ids in CardiogenicFl.ids in Cardiogenic

S!oc"S!oc" ive small volume boluses of ?ive small volume boluses of ?

10ml>kg10ml>kg

/" has myocarditis and because of/" has myocarditis and because of

this she has diastolic dysfunctionthis she has diastolic dysfunction

giving her extra Guid may overloadgiving her extra Guid may overload

her heart4her heart4


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Ionotropes1CardiotonicsIonotropes1Cardiotonics

&oamine%o= dose increases renal and&oamine%o= dose increases renal and

slanchnic blood Go=, high dose increasesslanchnic blood Go=, high dose increases

) and S4) and S4

&obutamine .ncreases contractility, may&obutamine .ncreases contractility, may

reduce S, $4reduce S, $4

'ilrinone.notroy and venodilation4'ilrinone.notroy and venodilation4

.mrove contractility and decrease after.mrove contractility and decrease after

loadload


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Ionotropes1 CardiotonicsIonotropes1 Cardiotonics

!inehrine .ncreases ),S and!inehrine .ncreases ),S and

contractility4 !nd ointadequate :$,contractility4 !nd ointadequate :$,

accetable tachycardiaaccetable tachycardia

"oreinehrine040?140mcg>kg>min4 .ncreases"oreinehrine040?140mcg>kg>min4 .ncreases

S4S4

:e hesitant to use either of these drugs for /" as:e hesitant to use either of these drugs for /" as

they increase myocardial oxygen consumtionthey increase myocardial oxygen consumtion


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T0's Hospital Co.rseT0's Hospital Co.rse

10ml>kg bolus =ith normal saline10ml>kg bolus =ith normal saline

results in minimal elevation of bloodresults in minimal elevation of blood

ressureressure

Started on &oamine of ?mcg>kg>minStarted on &oamine of ?mcg>kg>minand 'ilrinone 04? mcg>kg>minand 'ilrinone 04? mcg>kg>min

Stable for transort to *ardiac .*#Stable for transort to *ardiac .*#

(ttemted intubation results in(ttemted intubation results incirculatory collase/" goes u oncirculatory collase/" goes u on

!*'O!*'O


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Ot!er ca.ses oOt!er ca.ses o

Cardiogenic S!oc"Cardiogenic S!oc" &ysrhythmia&ysrhythmia

.nfection.nfection

'etabolic'etabolic ObstructiveObstructive

&rugs&rugs

*ongenital heart disease*ongenital heart disease /rauma/rauma


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Case 2Case 2

6 year old boy S resents =ith 5 day h>o fever,6 year old boy S resents =ith 5 day h>o fever,malaise4 )e has a ast history of nehroticmalaise4 )e has a ast history of nehroticsyndrome4O>!'inimally resonsive,skin aearssyndrome4O>!'inimally resonsive,skin aearsGushed and =arm, and he has bounding ulses4 )Gushed and =arm, and he has bounding ulses4 )1C0 50 :$60 systolic, sats@@B41C0 50 :$60 systolic, sats@@B4

Dhat tye of shock does the atient haveDhat tye of shock does the atient have

#ncomensated distributive shock Darm setic shock#ncomensated distributive shock Darm setic shock Dhat medications could be used in the managementDhat medications could be used in the management

of this atientEof this atientE

-luid, antibiotics, ressors, steroids-luid, antibiotics, ressors, steroids


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Septic S!oc"Septic S!oc"

'ediator release both exogenous'ediator release both exogenous

and endogenous lead toand endogenous lead to

misdistribution of blood, imbalancemisdistribution of blood, imbalance

of oxygen suly and demand,of oxygen suly and demand,alterations in metabolism andalterations in metabolism and

cardiac dysfunctioncardiac dysfunction


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)ar$ S!oc")ar$ S!oc"

!arly comensated hyerdynamic!arly comensated hyerdynamic

state of setic shockstate of setic shock

Darm extremities, bounding ulses,Darm extremities, bounding ulses,

tachycardia, =ide ulse ressure,tachycardia, =ide ulse ressure,

decreased systemic vasculardecreased systemic vascular

resistance and increased cardiacresistance and increased cardiac

oututoutut Often =ith hyerglycemiaOften =ith hyerglycemia


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Cold S!oc"Cold S!oc"

%ate uncomensated stage of setic%ate uncomensated stage of setic

shock =ith dro in cardiac oututshock =ith dro in cardiac outut

and increased Sand increased S

*old and clammy skin, raid thready*old and clammy skin, raid thready

ulses, shallo= breathingulses, shallo= breathing

(ssociated metabolic acidosis,(ssociated metabolic acidosis,

hyoxia, coaguloathy,hyoxia, coaguloathy,

hyoglycemia, caillary leakhyoglycemia, caillary leak


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PA+S A+3ORITH%PA+S A+3ORITH%

11S/S/hour20ml>kg>boluses4hour20ml>kg>boluses4

*orrect hyoglycemia and*orrect hyoglycemia and

hyocalcemia4hyocalcemia4

(dminister 1(dminister 1ststdose of antibioticsdose of antibiotics

*onsider vasoressor dri and stress*onsider vasoressor dri and stress

dose hydrocortisonedose hydrocortisone &!/!'."! D)!/)! -%#.&&!/!'."! D)!/)! -%#.&

!S$O"S.!!S$O"S.!


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.- "O/ -%#.& !S$O"S.!.- "O/ -%#.& !S$O"S.!

"ormotensiveStart &oamine"ormotensiveStart &oamine

)yotensive vasodilated8=arm shock9)yotensive vasodilated8=arm shock9"oreinehrine"oreinehrine

)yotensive vasoconstricted8cold)yotensive vasoconstricted8cold

shock9!inehrineshock9!inehrine!(%#(/! '.X!& !"O#S S(/,!(%#(/! '.X!& !"O#S S(/,

O(%MC0BO(%MC0B


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RS( Hospital Co.rseRS( Hospital Co.rse

100ml>kg of Guid is given, :$ imroves to100ml>kg of Guid is given, :$ imroves to

A0>50A0>50

Started on "oreinehrine dri follo=ingStarted on "oreinehrine dri follo=ing

=hich :$ imroves to systolic of @04=hich :$ imroves to systolic of @04 t .; laced ScO2C6Bt .; laced ScO2C6B

)ydrocortisone 2mg>kg1 dose given)ydrocortisone 2mg>kg1 dose given

Starts ancomycin and *eftriaxoneStarts ancomycin and *eftriaxone

'icrobiology calls to tell you there are ram'icrobiology calls to tell you there are ram

"eg rods on blood culture smear"eg rods on blood culture smear


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ScvO2MC0B, %o= :$, =arm shock(dditionalScvO2MC0B, %o= :$, =arm shock(dditionalGuid4 "oreinehrine 7> asoressinGuid4 "oreinehrine 7> asoressin

ScvO2NC0B, normal :$, oor erfusionScvO2NC0B, normal :$, oor erfusion/ransfuse to )bM10g>dl4 *onsider milrinone>/ransfuse to )bM10g>dl4 *onsider milrinone>nitrorusside>dobutaminenitrorusside>dobutamine

ScvO2NC0B, lo= :$, oor erfusionScvO2NC0B, lo= :$, oor erfusion/ransfuse to )bM10g>dl4 *onsider/ransfuse to )bM10g>dl4 *onsidereinehrine or dobutamine 7noreinehrineeinehrine or dobutamine 7noreinehrine

(&!"(% ."S#--.*.!"*Y(&!"(% ."S#--.*.!"*Y

)ydrocrtisone 2mg>kg)ydrocrtisone 2mg>kg


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Ho4 $.c! 5.id is toHo4 $.c! 5.id is to

$.c!6$.c!6 -luids in early setic shock *arcillo,-luids in early setic shock *arcillo,;('( 1kg in Frst hour5 'ore than 60cc>kg in Frst hour

"O &.--!!"*! ." (&S"O &.--!!"*! ." (&S:!/D!!" O#$S:!/D!!" O#$S


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Concl.sionsConcl.sions

ecognise shock quicklytachycardiaecognise shock quicklytachycardia

is the Frst sign, hyotension is lateis the Frst sign, hyotension is late

ain access quicklyif needed use .O4ain access quicklyif needed use .O4

$. better than a central line$. better than a central line

.f atient is not resonding the =ay.f atient is not resonding the =ay

you think broaden your diIerential,you think broaden your diIerential,

think about other tyes of shock4think about other tyes of shock4

Documents

Shock Resident Lecture