shock2
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Transcript of shock2
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SHOCKEmergency pediatric – PICU division
Pediatric Department
Medical Faculty, University of Sumatera Utara – H. Adam Malik Hospital
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Definition
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Shock is an acute, complex state of circulatory dysfunction that results in failure to deliver sufficient amounts of oxygen and other nutrients to meet tissue metabolic demands
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PathophysiologyPathophysiology
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 = Cardiac OutputSVR = Systemic Vascular resistanceSV = Stroke VolumeHR = Heart Rate
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Clinical Manifestation
Clinical Sign Compensated Uncompensated Irreversible
Heart rateSystolic BPPulse volumeCapillary refillSkinRespiratory rateMental state
Tachycardia +NormalNormal/reducedNormal/increasedCool,paleTachypnoea +Mild agitation
Tachycardia ++Normal or fallingReduced +Increased +Cool,mottledTachypnoea ++LethargicUncooperative
Tachycardia /bradicardiaPlummeting Reduced ++Increased ++Cold,deathly paleSighing respirationReact only to pain orunresponsive
Three phases: compensated, uncompensated, irreversible
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Management
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• Intubation & mechanical ventilation• Fluid resuscitation• Vasoactive infusion
• Intubation & mechanical ventilation• Fluid resuscitation• Vasoactive infusion
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FUNCTIONAL CLASSIFICATION
• Hypovolemia• Cardiogenic• Obstructive• Distributive• Septic• Endocrine
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HYPOVOLEMIC SHOCK
• A decrease in intra vascular blood volume to such an extent that effective tissue perfusion can not be maintain
• Most common cause of shock in infants & children• Etiology:
– Hemorrhage– Plasma loss– Fluid & electrolyte loss
• Hypovolemia ↓ preload ↓ SV ↓ CO
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CLINICAL MANIFESTATION:• Tachycardia• Skin mottling• Prolonged capillary refill• Cool extremities• ↓ UOP• 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
Continuous monitoring of HR, arterial BP, CVP, UOP Continuous 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 filling pressure rises without evidence of improvement in cardiovascular performance
Discontinue fluid resuscitation
Inotropic agent (+)
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REFRACTORY SHOCK:
– Unrecognized pneumothorax / pericardial effusion– Intestinal ischemia– Sepsis– Myocardial dysfunction– Adrenal cortical insufficiency– Pulmonary hypertension
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CARDIOGENIC SHOCK
• The pathophysiologic state in which abnormality of cardiac function is responsible for the failure of the cardiovascular system to meet the metabolic needs of tissue
Depressed CO• Etiology: Heart rate abnormalities, Cardiomyopathies/carditis,
Congenital heart disease, Trauma• Myocardial dysfunction is frequently a late manifestation of
shock of any etiology
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CLINICAL MANIFESTATION• Tachycardia• Hypotensive• Diaphoretic• Oliguria• Acidotic• Cool extremities• 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 optimized• 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– 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– 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 / epidural
anesthesia, disruption of spinal cord, inappropriate administration vasodilatory medication
• 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 specific inflammatory response
• Modified criteria for SIRS:– 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• Septic shock: Sepsis with hypotension despite adequate fluid
resuscitation
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MANAGEMENT:• Early recognition• Antibiotics appropriate with microbiological examination• Initial fluid resuscitation 20 ml/kg boluses over 5-10
minutes up to 40-60 ml/kg in the first hour• Inotropic / vasopressor refractory to fluids• Mechanical ventilation refractory shock• Hydrocortisone• Glycemic control• Blood transfusion
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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/m 2
Persistent Catecholamine-resistant shock
Add vasodilator or type III PDE inhibitor with volume loading
Normal Blood Pressure Cold ShockSVC O2 Sat < 70%
Low Blood Pressure Cold ShockSVC O2 Sat < 70%
Titrater volume resuscitationand epinephrine
Low Blood Pressure Warm ShockSVC O2 Sat < 70%
Titrater volume and norepinephrine
60 min Draw baseline cortisol level Then give hydrocortisone
Draw baseline cortisol level or perform ACTH stim test. Do not give hydrocortisone
Not at risk ?
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 and Over 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
At risk of adrenal insufficiency ?
Fluid refractory-dopamine/dobutamine resistant shock
Fluid refractory shock**
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THANK YOU
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