Mk Icu Slide Shock

8/3/2019 Mk Icu Slide Shock

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SHOCK

Emergency pediatric PICU division

Pediatric Department

Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital

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Definition

Shock is an acute, complex state of

circulatory dysfunction that results in

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oxygen and other nutrients to meet tissue

metabolic demands


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Pathophysiology

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

SV

Preload

Myocard

Contractility

Pressure AfterloadHRSVR

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CO = Cardiac OutputSVR = Systemic Vascular resistance

SV = Stroke VolumeHR = Heart Rate


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Clinical Manifestation

Clinical Sign Compensated Uncompensated Irreversible

Heart rateSystolic BP

Pulse volumeCapillary refill

Tachycardia +Normal

Normal/reducedNormal/increased

Tachycardia ++Normal or falling

Reduced +Increased +

Tachycardia/bradicardia

PlummetingReduced ++

Three phases: compensated, uncompensated, irreversible

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SkinRespiratory rateMental state

Cool,paleTachypnoea +Mild agitation

Cool,mottledTachypnoea ++Lethargic

Uncooperative

Increased ++Cold,deathly paleSighing respiration

React only to pain orunresponsive


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Management

Intubation & mechanical ventilation

Fluid resuscitation

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FUNCTIONAL CLASSIFICATION

Hypovolemia Cardiogenic

Obstructive

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Distributive Septic

Endocrine


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HYPOVOLEMIC SHOCK

A decrease in intra vascular blood volume to such an extent thateffective tissue perfusion can not be maintain

Most common cause of shock in infants & children Etiology:

Hemorrhage

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asma oss Fluid & electrolyte loss

Hypovolemia preload SV CO


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CLINICAL MANIFESTATION:

Tachycardia

Skin mottling

Prolonged capillary refill

Cool extremities

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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

10Continuous monitoring of HR, arterial BP, CVP, UOPContinuous 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 fillin ressure rises without evidence of im rovement

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in cardiovascular performance

Discontinue fluid resuscitation

Inotropic agent (+)


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REFRACTORY SHOCK:

Unrecognized pneumothorax / pericardial effusion

Intestinal ischemia Sepsis

Myocardial dysfunction

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Adrenal cortical insufficiency Pulmonary hypertension


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CARDIOGENIC SHOCK

The pathophysiologic state in which abnormality of cardiacfunction is responsible for the failure of the cardiovascular

system to meet the metabolic needs of tissue

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epresse Etiology: Heart rate abnormalities, Cardiomyopathies/carditis,

Congenital heart disease, Trauma

Myocardial dysfunction is frequently a late manifestation ofshock of any etiology


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CLINICAL MANIFESTATION Tachycardia

Hypotensive

Diaphoretic Oliguria

Acidotic

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oo ex rem es

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 o timized

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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

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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

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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 / epiduralanesthesia, disruption of spinal cord, inappropriate

administration vasodilatory medication

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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 specificinflammatory response

Modified criteria for SIRS:

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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

Se tic shock: Se sis with h otension des ite ade uate fluid

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resuscitation


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MANAGEMENT:

Early recognition

Antibiotics appropriate with microbiological examination

Initial fluid resuscitation 20 ml/kg boluses over 5-10minutes up to 40-60 ml/kg in the first hour

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Mechanical ventilation refractory shock

Hydrocortisone

Glycemic control

Blood transfusion


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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 andOver 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

Fluid refractory-dopamine/dobutamine resistant shock

Fluid refractory shock**

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/m2

Persistent Catecholamine-resistant shock

Add vasodilator or type III PDE

inhibitor with volume loading

Normal Blood Pressure Cold Shock

SVC O2 Sat < 70%

Low Blood Pressure Cold Shock

SVC O2 Sat < 70%

Titrater volume resuscitation

and epinephrine

Low Blood Pressure Warm Shock

SVC O2 Sat < 70%

Titrater volume and

norepinephrine

60 minDraw baseline cortisol level

Then give hydrocortisone

Draw baseline cortisol level or perform

ACTH stim test. Do not give hydrocortisone

Not at risk ?At risk of adrenal insufficiency ?


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THANK YOUTHANK YOUTHANK YOUTHANK YOU

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