HOUSEOFFICER TEACHING

R.Nandinii(SHOCK)

Mentor: DR GOH SZE CHIA

◦ 4 years old, Malay, Girl, 20 kg

◦ Presented with:

-rapid breathing x 1/7

-fever & cough x 1/52

WHAT HISTORY WOULD YOU LIKE TO ELICIT?

-Rapid breathing x 1/7

a/w noisy breathing (audible wheezing),

No cyanosis

-Fever. High grade fever with chills & rigors.No rashes. No fit

-Cough.Chesty cough. Yellowish sputum. No prolonged cough, no post-tussive vomiting.

Less active for 2 days.

Interrupted sleep due to cough and rapid breathing

Not tolerating orally at all.

No AGE s/s. NBO for 2 days

Less PU – claimed only 2-3 times changing pampers for 2 days , yellow urine color

No abnormal behaviour,

no projectile vomiting, not irritable

No sick contact.

No recent fogging, no travelling, no hx of swimming

No known drug and food allergy

No hx of choking

1 week ago had seek treatment at GP and prescribed with paracetamol and antibiotic (whitish colour BD dosing) – completed for 5 days.

But symptoms did not improve.

HOW DO YOU APPROACH THIS

PATIENT?

◦Primary assessment◦Airway◦Breathing◦Circulation ◦Disability◦Exposure

◦ Secondary assessment

Primary assessmentAirway : - No secretion, no foreign body

Breathing : - Effort : RR : 50 / SCR/ICR/Suprasternal recession/nasal flaring/wheezing- Efficacy : SPO2 : 90 % under RA, Auscultation : bil crepts , gen rhochi, a/e equal b/L, equal chest

expansion - Effect : HR : 148 bpm/ good pulse volume(bounding) / CRT about 3 sec / pale / warm peripheries

Circulation : - HR : 148 bpm/ good pulse volume(bounding) / CRT about 3 sec/ - BP : 80/50 mmHg

Disability : Pupils : 3/3 reactive B/L, GCS : responded to verbal (AVPU), Dxt : 5 mmol/l , Posture : normal

Exposure : no skin rashes , warm peripheries , temp : 39 C, no bruises / petechia

Secondary assessment◦ Clinically pale, no cyanosis, appears lethargic, tachypneic with recession, toxic

looking

◦ Dry lips/ tongue, no sunken eyes, pulses bounding, capillary refill 3-4 sec, warm peripheries, skin turgor normal

◦ Throat : injected , tonsil not enlarged . Bil cervical LN palpable

◦ Lungs: Bilateral lower zone crepts with gen rhonchi, a/e equal good b/l , no dullness on percussion

◦ Abd: soft, not distended, BS +VE, liver palpable 2cm with upper border of liver @ 7Th ICS

◦ CVS : S1S2 heard, no murmur, apex beat not displaced

◦ CNS examination : normal

◦ No skin rashes / bruises noted

Diagnosis◦ Provisional diagnosis : ◦ Septic shock secondary to pneumonia with brochospasm

◦ Differential diagnosis ◦ Hypovolaemic shock ◦ TRO Urosepsis/ UTI

What blood investigations would you want to carry out?

◦ FBC

◦ RP/LFT

◦ VBG

◦ Blood c +s

◦ Urine feme

◦ Urine c+s

◦ CXR

HOW WOULD YOU APPROACH THIS

PATIENT?

◦ FMO2 or HFMO2 10L/min ◦ Keep SPO2 > 95% ◦ Neb salbutamol 1:3 stat and to reassess back post neb (might need continuous

neb)◦ Attach cardiac monitor and check vital signs◦ Put 2 large bore branula ◦ Send blood investigation : FBC/RP/ABG/DXT/LFT/ Blood C+S/ Coagulation

profile ◦ Radio imaging : CXR

◦ Give IV NS bolus 20ml/kg (400cc) over 10-15 minutes then reassess back patient. ◦ Keep NBM in view of child tachypneic ◦ Start IVD HSD5% (FM) + IVD 10% correction ◦ I/O chart- might consider continuous bladder drainage ◦ DXT 6 hourly ◦ GSC charting◦ Start IV C-Penicillin 50,000 u /kg/dose

INTERPRET THE FOLLOWING RESULTS:

◦ FBC : ◦ Hb : 10/WCC : 30 predominant neutrophils 88%/ PLT : 245/ Hct : 36

◦ RP : urea : 12 / Na : 135 / K+ : 4 / creat : 105

◦ VBG : ◦ pH : 7.20/ pCO2 : 25 / Hco3 : 16 / BE : - 12 / Po2 : 50

◦ LFT : Protein : 70/Alb : 42 / T.Bili : 10 / ALT : 18 / AST : 40 / ALP : 150

◦ Coagulation profile : normal

◦ UFEME : No UTI picture

◦ Urine C+S / Blood C+S: Pending

CXR

Final diagnosis:◦ Septic shock secondary to severe pneumonia with bronchospasm

◦ Decompensated metabolic acidosis

◦ Acute kidney injury secondary to severe dehydration

Back to the patient.◦ Reassess the patient (post bolus + post neb) :

◦ Airway : clear airway

◦ Breathing : ◦ RR : 50 , deep SCR,ICR ,suprasternal recession◦ SPO2 92 % under HFMO2 15L/min◦ Auscultation : gen rhonchi with crepts , reduced a/e bibasal

◦ Circulation : HR : 130 / BP : 75/50 / good pulse volume/ CRT = 3sec

◦ Disability : GCS : irritable, confused, pupils reactive

◦ Exposure : temp : 37.8

WHAT TO DO NEXT?

◦ Prepare for intubation ◦ ETT size : 4.5,5, 5.5 Fr◦ Length to anchored : 14 ◦ Sedation : IV midazolam 0.1 mg/kg ◦ Muscle paralysis : rocuronium /scholline (1mg/kg)

◦ Give another NS bolus 20ml/kg over 30 min and reassess back

◦ IV MgSO4 (50mg/kg) / IVI salbutamol loading dose for bronchospasm

Reassess post intubation◦ Airway : intubated

◦ Breathing : SPO2 : 100 % on Self inflating bag

◦ Circulation : CRT about 2sec, HR : 110 , BP : 90/60 2nd bolus in progress

◦ Disability : sedated and intubated

◦ Repeat ABG/VBG post intubation ◦ VBG result : pH : 7.25 / pCO2 : 50 / PO2 : 60 /HCo3 : 15 / BE : - 8

◦ Frequent vs monitoring ◦ HR / BP / RR / SPO2 ◦ BP monitoring every 15-30 min until BP stable

◦ Might consider inotropes (IV dopamine)

◦ Order for CXR to confirm position of ETT

◦ Once pt stabilize , consider to transfer pt to PICU for ventilatory support.

What is shock?◦ Shock is a syndrome that results from inadequate oxygen delivery

to meet metabolic demands.◦ Untreated ; this leads to metabolic acidosis, organ dysfunction

and death

Stages of shock� Compensated

– Vital organ function maintained, BP remains normal.� Uncompensated

– Microvascular perfusion becomes marginal. Organ and cellular function deteriorate. Hypotension develops.

� Irreversible

Types of shock

TYPE EXAMPLES

Hypovolemic Hemorrhage Fluid loss Drugs

Distributive Analphylactic Neurogenic Septic

Cardiogenic Myocardial dysfunction Dysarrhythmia Congenital heart disease

Obstructive Pneumothorax, CardiacTamponade, Aortic Dissection

SIRS/Sepsis/Septic shock

Mediator release:

exogenous & endogenous

Maldistribution

of blood flow

Cardiac

dysfunction

Imbalance of oxygen

supply and demand

Alterations in

metabolism

Septic Shock

Warm septic shock

• Early, compensated, hyperdynamic

• Clinical Signs-confusion -Warm extremities– bounding pulses, TACHYCARDIA, tachypnea

• Physiologic Parameters– Wide pulse pressure, increased CO, decreased SVR

Cold septic shock

• Late, uncompensated with decreased CO

• Clinical Signs– Cyanosis, cold, clammy, mottled skin–Rapid, thready pulses with shallow respirations– Thrombocytopenia, oliguria, myocardial dysfunction, capillary leak

� Cold Shock rapidly progresses to multiorgan system failure or death if untreated

� Multi-Organ System Failure: Coma, ARDS, CHF, Renal Failure, Ileus or GI hemorrhage, DIC

� More organ systems involved, worse the prognosis� Therapy: ABCs, fluid� Appropriate antibiotics, treatment of underlying

cause

Septic Shock

Management-General Goal: increase oxygen delivery and decrease oxygen demand:

For all children:○ Oxygen ○ Fluid ○ Temperature control○ Correct metabolic abnormalities

Treat underlying cause○ To start antibiotics

Algorithm for time sensitive, goal-directed stepwise management of hemodynamic support in infants and children Reproduced from BrierleyJ, Carcillo J, Choong K, et al: Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the AmericanCollege of Critical Care Medicine. Crit Care Med 2009; 37:666–688.

Take home points:Early Recognition

Early goal directed therapy

Remember golden hour

Early and emperical antimicrobials

Early source control and aggressive therapy