Houseofficer teaching-paeds:shock
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Transcript of Houseofficer teaching-paeds:shock
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