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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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