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Circulation Failure

(Shock)

PEDIATRIC EMERGENCY DEPARTMENT

MEDICAL FACULTY


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SHOCK

Acute syndrome that occurs because of cardiovascular

dysfunction and the inability of the circulatory system to

provide adequate oxygen and nutrients to meet themetabolic demands of vital organs

Cardiac Output = Heart rate x Stroke Volume

CO = HR x SV


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Shock phase

1. Compensated

- Early homeostatic mechanism will maintain vitalorgan function

- Blood pressure, urine output & cardiac functionis still normal

2. Uncompensated- Circulation failure

- Toxic material released

- Vital organ disturbance

3. Irreversible

- Cell damage cell death

- Multi organ system dysfunction


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Shock Clinical Manifestation

Clinical signs Compensated UncompensatedIrreversibleBlood loss (%) < 25 25-40 > 40

Heart rate tachycardia + tachycardia ++ tachycardia/ bradicardia

Systolic BP normal normal/ falling plummeting

Pulse volume normal/ reduce reduced + reduced ++

Capillary refill normal/ increase increase + increase ++

Skin cool, pale cold, mottled cold, deathly pale

Respiratory rate tachypnoea + tachypnoea ++ sighing respiration

Mental state mild agitation lethargic/ uncooperative reacts only to pain/

unresponsive


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Typesof Shock

1. HYPOVOLEMIC

decreased circulating blood volume

2. DISTRIBUTIVE

misdistribution of normal intravascular volume

3. CARDIOGENIC

cardiac pump failure

4. OBSTRUCTIVE

obstruction of cardiac filling/out flow


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ETIOLOGI

1. Hypovolemic

Dehydration, Hemorrhage, Capillary leaks

2. DistributiveVasodilatation venous pooling decrease preload

Anaphylaxis, sepsis, drug intoxication, trauma, spinal cordinjury

3. CardiogenicCongenital heart disease, myocarditis, dysritmia

4. Obstructive Cardiactamponade, tension pneumothorax, pulmonary

embolus


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PATHOPHYSIOLOGY OF SHOCK

COMPENSATED

HIPOVOLEMIC SHOCK

PRELOAD

CARDIACOUTPUT BLOOD PRESSURE

SYMPHATETIC DISCHARGE

VASOCONSTRICTIONHR

CONTRACTILITY

UNCOMPENSATED

MYOCARDIAL PERFUSION

MYOCARDIAL O2CONSUMPTION

TISSUE ISCHEMIA

CARDIACOUTPUT

Loss of auto regulation

MEDIATOR RELEASE of microcirculation

CELL FUNCTION

CELL DEATH

DEATHOF ORGANISM

Diadaptasi dari : White MK, Hill JH, Blumer JL : Shock in the pediatric patient,

Adv Pediatr 34:139-174, 1987


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Diagnosis

History Etiology ? Most caused : hypovolemia(dehydration, hemorrhagic), sepsis and congenital

hearth disease, respectively

Physical examination - Cardiovascular status : heart rate, polls, capillary

refill, blood pressure

- Other vital organs : respiration rate & type,consciousness, skin perfusion (pale, mottled,

cyanosis), temperature, urine output


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Laboratory Data

routine blood (Hb , Ht , thrombocytopenia, leucocytosis,

neutropenia), renal function test (BUN, creatinine ), liver

function test, electrolyte, hypoglycemia, arterial blood gas, blood

culture, routine urine


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TREATMENT& MONITORING

A. InitialResuscitation

- Ventilation

- Oxygenation(FiO2 100%)

- Vascularaccess(60-90 second

not successful intra osseous)

20 ml/ kgbw (


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InitialMonitoring

1. Monitoringcardiovascular/ vitalsigns and peripheral

perfusionafterfluid challenge (loading)

2. Urine Catheter > 1 ml/ kgbw/ hour

3. Laboratory analysis: urine & blood, blood gas analysis,

glucose & electrolyte, culture


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B. NextResuscitation

1. Ifnotrespond after 2-3 xfluid challenge intubations & ventilation support

2. Evaluation blood gas analysis, and corrected : -

metabolic acidosis (pH < 7,15) natrium bicarbonate

8,4% 1 meq /kgbw (ventilation adequate)- respiratory acidosis ventilator pulse ox meter for

perfusion monitoring -

hypocalcaemia, hypoglycemia and electrolyte

3. If hypotension (+) and polls (-) catheter central venous andgive fluid according CVP

4. Inotropic drugs

5. Blood Transfusion ifHb < 5 g/dl ( 10 ml/ kgbw)


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INOTROPIC DRUGS

DRUG DOSE EFFECT

Dopamine 1-4 ug/kg/mnt Vasodilator splanchivic5-10 ug/kg/mnt Contractility

>10-15 ug/kg/mnt Vasoconstriction Isoproterenol

0,1-1,0 ug/kg/mnt Contractility

Vasodilator peripheral Dobutamine

1-15 ug/kg/mnt Contractility Epinephrine0,1-0,2 ug/kg/mnt Contractility

resistance

systemic vascular

0,5-1,5 ug/kg/mnt resistance systemicvascular

Bolus 10-20 ug/kg/mnt contractility

resistance

systemic vascular

Ca-chloride 10-20 mg/kg contractility


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ResuscitationMonitoring

- Whatstheetiology ?

Consultstootherdivision

- Evaluationand treatmentforotherorgans

: renal, liver, heart, lung, CNS

- Laboratory, ECG and x-ray photo


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FluidResuscitation

1. Crystalloid

- Normalsaline(NaCl0,9%)

- Isotonic fluid: * Ringerslactate

* Ringersacetate

* Normosol, Plasma-lyte, etc

* Bloodvolume

* Changelossextracellular fluid

* Inducteddiuresis* Cheap


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2. Colloid

- Blood* Whole blood* Low titer - O negative (donor universal)

* Cross matched

* Washed erythrocyte

- Plasma and its component

* Plasma (Fresh frozen)

* Albumin* Plasmanate

- Molecule weight >> capillary wall


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- Benefit :

* A little colloid volume intravascular >>

* Colloid osmotic pressure lung edema rare

- Side effect :

* Anaphylactic reaction

* Affected clothing time

* Expensive


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Thank you

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