shock-presentation Year 4 Paediatrics Notes OmpathStudy

shock-presentation Year 4 · Paediatrics Collection: 4TH YEAR ALL NOTES / PAEDS / PAEDS 4.3 / Agisa -- Slide 1 Pediatric Shock Slide 2 Learning Objectives Define shock Know the stages of shock Know the classifications of shock and generate differential diagnosis of etiology Know the initial management of shock Slide 3 What is shock? Inadequate perfusion to meet tissue demands. A progressive process. Occurs in 2% of hospitalized patients.\nMortality 10% in children (without MODS), vs. 30-40% in adults. 1,2 In other words, a systemic reduction in tissue perfusion  decreased tissue O2 delivery.\nA shift to less-efficient anaerobic metabolism, leading to lactic acidosis, occurs. Initially, effects are reversible. Eventually:\nCell membrane ion pump dysfunction Cellular edema, leakage of cells’ contents Inadequate regulation of intracellular pH  Cell death, organ failure, cardiac arrest, and death. Slide 4 Stages of Shock A progressive process: Intervene early Compensated Shock: Cardiac output (HR x SV) and systemic vascular resistance (peripheral vasoconstriction) work to keep BP within normal.\nOn exam: Tachycardia; decreased pulses & cool extremities in cold shock; flushing and bounding pulses in warm shock; oliguria; labs may show mild lactic acidosis Hypotensive (Uncompensated) Shock: Compensatory mechanisms are overwhelmed. On exam: As above, plus hypotension, altered mental status; labs may show increased lactic acidosis Generally quick progression to cardiac arrest. Irreversible Shock: Irreversible organ damage, cardiac arrest, death occur. Slide 5 Classifications of Shock Hypovolemic Shock Decreased preload due to internal or external losses. Distributive Shock Decrease in SVR, with abnormal distribution of blood flow  functional hypovolemia, decreased preload. Typically, NL or  CO. Cardiogenic Shock “Pump failure.”  CO, systolic function. Obstructive Shock Outflow from left or right side of heart physically obstructed. Slide 6 Physiologic profiles of shock states Slide 7 Case 1 15-year-old previously well boy had surgery for partial small bowel resection after multiple gunshot wounds to the abdomen. The nurse notes that his HR has increased in the last hour from 90 to 130, despite adequate pain management. On exam, he is afebrile, HR is 140, BP 80/50. Cap refill is 3 seconds in his cool extremities and pulses are 1+.\n What is your assessment? What is the stage of shock? What is the classification of shock? What is your initial management? Slide 8 General initial management Overall goal: Normalization of BP and tissue perfusion. Physiologic indicators that should be targeted include:1 Blood pressure: Normal (defined in next slide). Quality of central and peripheral pulses: Strong, distal pulses equal to central pulses. Skin perfusion: Warm, with capillary refill 1-2 seconds. Mental status: Normal. Urine output: 1 mL/kg per hour, once effective circulating volume is restored. Slide 9 Shock: Evaluation pearls Tachycardia? - Non-specific early finding. Investigate further. Skin changes? - Typically, prolonged cap refill (vasoconstriction) with compensated shock. Flash refill with early distributive shock and with irreversible shock. Impaired mental status? - Defining mental status as accurately as possible (GCS) is key to monitoring progression. Assess for yourself -- don’t rely on other providers. Oliguria? - Watch for decreased GFR; re-order meds accordingly. Hypotension? - Late finding. Don’t accept from others that BP is “normal.” Widened pulse pressure ( 40 mmHg)? - May be present in distributive shock, aortic insufficiency, AVMs, Cushing’s reaction Slide 10 Case 2 6-year-old previously well girl is admitted to your ward directly from clinic with fever, bloody diarrhea x 1 day. She’s had no urine x 24 hrs and is becoming harder to awaken. On exam, her HR is 150, BP 72/30, temp 103. She’s sleepy but arousable. She’s flushed with capillary refill <1 second.\n What is your assessment? What is the stage of shock? What is the classification of shock? What is your differential for the etiology? What is your initial management? If a higher level of care is needed, how would you obtain it? Slide 11 Goal-directed algorithm 1-3 Algorithm is based on consensus recommendations for septic shock in children, mostly extrapolated from adult data. May initially be applied to any patient in shock, regardless of etiology. Exact etiology must be sought to identify which patients may not respond and to tailor therapy. Slide 12 Management: Goal-directed algorithm First 5-15 min: ABCs (and D’s: dextrose, disability) Attach CRM, change vital sign measurements to appropriate interval (q 15 min), alert nurses of concerns. Identify life-threatening conditions and establish access. Place 2 large bore PIVs if possible; ensure established lines are working. If no IV access and uncompensated, PALS says go for I/O immediately. Give 20 ml/kg crystalloid over 5-10 min. Begin w/ 5-10 ml/kg if suspect cardiogenic shock, DKA. Give e