This document outlines the approach to a child presenting with shock. It discusses the different types of shock including hypovolemic, cardiogenic, distributive, obstructive, and septic shock. The diagnosis of shock is made based on history, physical exam, and investigations. Management involves stabilizing the airway and circulation, administering fluid boluses, treating the underlying cause, and considering vasoactive drugs or inotropes. Outcomes depend on the type of shock, but early recognition and treatment can reduce mortality rates.

1. DEPARTMENT OF PEDIATRICS AND CHILD
HEALTH
APPROACH TO CHILD WITH SHOCK
Moderator : Dr.YOSEPH BACHA (R2)
Presentor: Dr.DEJENE HUMNA (MI)
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APPROACH TO CHILD WITH SHOCK

2. Out-lines
• Introduction
• Types of shock
• Diagnosis of shock
• Management of shock
• Shock in malnourished children
• Refractory shock
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3. INTRODUCTIOPN
• Shock is an acute syndrome characterized by the
body's inability to deliver adequate oxygen to meet
the metabolic demands of vital organs and tissues.
• Occurs in approximately 2% of all hospitalized
infants, children, and adults in developed countries,
• Most patients die as a result of associated
complications and multiple organ dysfunction
syndrome (MODS).
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4. TYPES OF SHOCK
 Shock classification systems generally define 5
major types of shock
1. Hypovolemic shock
2. Cardiogenic shock
3. Distributive shock
4. Obstructive shock
5. Septic shock
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5. TYPES OF SHOCK….
Hypovolemic shock
 The most common cause of shock in children
worldwide
 Potential etiologies
• Blood loss: hemorrhage
• Plasma loss: burns, Nephrotic syndrome
• Water/electrolyte loss: vomiting, diarrhea
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APPROACH TO CHILD WITH SHOCK

6. TYPES OF SHOCK….
Cardiogenic shock
• Cardiac pump failure secondary to poor myocardial
function
• Potential etiologies
– Congenital heart disease
– Cardiomyopathies: infectious or acquired, dilated
or restrictive
– Ischemia
– Arrhythmias
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7. TYPES OF SHOCK….
Distributive shock
 Abnormalities of vasomotor tone from loss of venous
and arterial capacitance
 Can lead to functional hypovolemia with decreased
preload .
 Etiologies
 Anaphylaxis
 Neurogenic: loss of sympathetic vascular tone
secondary to spinalcord or brainstem injury
 drugs
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APPROACH TO CHILD WITH SHOCK

8. TYPES OF SHOCK….
Obstructive shock
• Lesion that creates a mechanical barrier that impedes
adequate cardiac output
• Decreased venous return
• includes
– Pericardial tamponade
– Tension pneumothorax
– Pulmonary embolism and
– ductus-dependent congenital heart lesions
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APPROACH TO CHILD WITH SHOCK

9. TYPES OF SHOCK….
Septic shock
• Usually involves a more complex interaction of
distributive, hypovolemic, and cardiogenic shock.
• Causes are
• Bacterial
• Viral
• Fungal
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APPROACH TO CHILD WITH SHOCK

10. Diagnosis
• History
• Physical Examination
• Investigations
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11. diagnosis…..
History
• A history of fluid loss
• trauma history
• Fever and/or immunocompromise
• HX of chronic heart disease
• Hx of chronic steroid therapy,
• Hx of exposure to an allergen
• Hx of decreased urine output
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APPROACH TO CHILD WITH SHOCK

12. Physical Examination
• Change in mentations
• Children with shock are usually tachypnea.
• Tachycardia is a consistent sign of shock
• Prolonged capillary refill
• Absent distal pulses, cool extremities
• Abdominal distention, mass, or tenderness
• Children with shock may have normal BP
• Temperature – Fever (or hypothermia in young
infants) is often consistent with septic shock.
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13. Investigations
• CBC, Blood group and cross match
• RBS
• Serum electrolytes
• Urine analysis
• S/E
• RFT
• Serum lactic acid level
• Coagulation profile
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APPROACH TO CHILD WITH SHOCK

14. Management of shock
• Early recognition
• Stabilization of airway,
• breathing, and
• circulation
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15. Management of shock….
• Depending on the severity of shock, further airway
intervention, including:
-intubation and
-mechanical ventilation,
• Immediately following establishment of intravenous
(IV) or intraosseous access, therapy should be
initiated
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16. 1.Management hypovolemic shock
• Aggressive fluid resuscitation and control of ongoing
losses
• Subsequent repletion of deficits
• Correction of metabolic abnormalities
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APPROACH TO CHILD WITH SHOCK

17. 1.Management hypovolemic shock….
• Rapid IV administration of 20 mL/kg isotonic fluid
should be initiated
• This bolus should be repeated quickly up to 60-
80ml/kg
• Not improved after total of 60 mL/kg of isotonic
fluid Concider other causes of shock.
• Rapid improvement occurs with initial fluid
administration.
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APPROACH TO CHILD WITH SHOCK

18. 1.Management hypovolemic shock…
• After the initial fluid bolus:
- Strong peripheral pulses
-Skin perfusion (warm, with capillary refill <2
seconds)
-Normal mental status
-Urine output (≥1 mL/kg/hr)
-Blood pressure (systolic pressure at least fifth
percentile for age:
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19. 1.Management hypovolemic shock…….
• Hemorrhagic shock should receive blood
• Require definitive treatment for the cause of
hemorrhage
• PRBC should be infused in 10 mL/kg boluses.
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APPROACH TO CHILD WITH SHOCK

20. 1.Management hypovolemic shock…
• If shock remains refractory following 60-80 mL/kg of
volume resuscitation,
• vasopressor therapy should be instituted while
additional fluids are administered.
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21. 1.Management hypovolemic shock…
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22. 1.Management hypovolemic shock…
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23. 1.Management hypovolemic shock…
• Shock in severe acute malnutrition:
– considered to have shock in lethargic or unconscious
- NS or RL with 5% glucose at 15 ml/kg over 1 hr.(half-
strength Darow solution with 5% glucose).
• Pulse and breathing rate every 5-10 minutes.
• Discontinue iv infusion if either of these increase (pulse by
15,RR BY 5).
• Change IV fluid with oral intake/Resomal after 2 hrs.
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24. 1.Management hypovolemic shock…
• If there is improvement:repeat 15ml/kg over 1hr.
• If no improvement:give maintainance IV fluid
4ml/kg/hr while waiting for blood.
• Trasfuse fresh whole blood 10ml/kg/hrs slowly
over(use packed cells if in cardiac falure)
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25. 2.Management septic shock
• Early administration of broad-spectrum antimicrobial
agents
• Neonates should be treated with ampicillin plus
cefotaxime and/or gentamicin
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APPROACH TO CHILD WITH SHOCK

26. 2.Management septic shock ….
• Community-acquired infections with Neisseria
meningitidis treated empirically with a 3rd-generation
cephalosporin
• Haemophilus influenzae treated empirically with a
3rd-generation cephalosporin
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APPROACH TO CHILD WITH SHOCK

27. 2.Management septic shock ….
• Vigorous fluid resuscitation
• Begin with a bolus of 20 mL/kg of isotonic
crystalloid solution as rapidly as possible.
• Repeated up to 60-80ml/kg,and reassess
• Consider vasoactive therapy
• Corrected Hypoglycemia
• Calcium gluconate 10 percent solution in a dose of 50
to 100 mg/kg
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APPROACH TO CHILD WITH SHOCK

28. 3.Management Distributive shock
• Caused by a primary abnormality in vascular tone,
• Early initiation of a vasoconstrictive agent to
increase SVR
• Either phenylephrine or vasopressin and
epinephrine for anaphylaxis.
• Epinephrine improve the myocardial activities
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APPROACH TO CHILD WITH SHOCK

29. 4.Management Cardiogenic shock
• Decompensate quickly when fluid administered.
• Poor cardiac output with a compensatory elevation in
SVR.
• Smaller boluses (5-10 mL/kg) should be given to
replace deficits and maintain preload
• further administration of fluids should be provided
judiciously.
• Early initiation of epinephrine or dopamine
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30. 4.Management Cardiogenic shock….
• Poor peripheral perfusion and acidosis may persist
• Milrinone improve systolic function and decrease
SVR without causing a significant increase in heart
rate
• Enhancing diastolic relaxation
• Dobutamine or nitroprusside,
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31. 4.Management Cardiogenic shock….
• Improvement peripheral perfusion, urine output,
mental status and resolution of acidosis
• Norepinephrine and vasopressin, should be avoided
• Further decompensation and precipitate cardiac
arrest as a result of the increased afterload
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32. 5.Management Obstructive shock
• Fluid resuscitation may be briefly temporizing in
maintaining cardiac output,
• The primary insult must be immediately addressed.
• Life saving therapeutic interventions
• Pericardiocentesis,chest tube thrombectomy/thrombolysis
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33. Follow up
• Electrolyte levels should be monitored closely.
• Hypoglycemia should treated
• Hypocalcemia, should be treated with a goal of
normalizing the ionized calcium concentration
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34. Refractory shock
• Considered steroid unresponsive to fluid
resuscitation and catecholamines.
• Adrenal function is another important
consideration in shock, and hydrocortisone
replacement may be beneficial.
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35. Refractory shock…
• Up to 50% of critically ill patients have adrenal
insufficiency.
• Patients with congenial adrenal hypoplasia, abnormalities
of the hypothalamic-pituitary
• And recent therapy with corticosteroids.
• These patients should receives tress doses of
hydrocortisone
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APPROACH TO CHILD WITH SHOCK

36. PROGNOSIS
• In septic shock, mortality rates 3% in previously
healthy children
• And 6-9% in children with chronic illness (compared
with 25-30% in adults)
• Early recognition and therapy, can reduce the
mortality rate
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37. REFERENCE
• DavidA.T urner ,Ira M. Cheifetz Nelson T extbook of
Pediatrics page 2706-2741
• uptodate 21.2,(markwaltman.md ,Initial evaluation of shock
in children
• ETAT Ethiopia manual for participants 2014(page-38)
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38. Thank you
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