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  1. 1. PEDIATRICS SHOCK MANAGMENT Presenter Anteneh Tafere(R2) Moderator, Dr. Muluwork Tefera (pediatrics emergency and critical care specialist) 21/4/2022 1
  2. 2. Outline • Definition • Epidemiology • Pathophysiology • Classification • Management • Prognosis • reference 21/4/2022 2
  3. 3. Definition • Acute process characterized by the body's inability to deliver adequate oxygen to meet the metabolic demands of vital organs and tissues • Insufficient oxygen at the tissue level is unable to support normal aerobic cellular metabolism • Resulting in a shift to less efficient anaerobic metabolism 21/4/2022 3
  4. 4. Epidemiology • Shock occurs in approximately 2% of all hospitalized infants, children, and adults in developed countries • Mortality rate varies substantially depending on the etiology and clinical circumstances 21/4/2022 4
  5. 5. • Of patient who do not survive most do not die in the acute hypotensive phase of shock but rather as a result of associated complication and MODS • MODS is defined as any alteration of organ function that require support for maintenance 21/4/2022 5
  6. 6. Pathophysiology • An initial insult triggers shock, leading to inadequate oxygen delivery to organs and tissues • Compensatory mechanisms attempt to maintain blood pressure by increasing cardiac output and systemic vascular resistance 21/4/2022 6
  7. 7. • The body also attempts to optimize oxygen delivery to the tissues by increasing oxygen extraction and redistributing blood flow to the brain, heart, and kidneys at the expense of the skin and gastrointestinal tract 21/4/2022 7
  8. 8. Con’d • In the early phases of shock, multiple compensatory physiologic mechanisms act to maintain BP and preserve tissue perfusion and oxygen delivery -Cardiovascular effect Increases in heart rate, stroke volume, and vascular smooth muscle tone w/c are regulated through sympathetic nervous system and neuro humeral 21/4/2022 8
  9. 9. Con’d - Respiratory compensation involves Greater carbon dioxide elimination in response to metabolic acidosis and increased CO2 production for poor tissue perfusion - Renal excretion of hydrogen ions and retention of bicarbonate 21/4/2022 9
  10. 10. Con’d • Despite this compensatory mechanism, the underling shock and host response lead to vascular endothelial cell injury and significant leakage of intravascular fluid into interstitial extracellular space • Another aspect of initial pathophysiology of shock is the impact on cardiac output response 21/4/2022 10
  11. 11. b Sequence of pathophysiologic events in clinical shock states 21/4/2022 11
  12. 12. 21/4/2022 12
  13. 13. • Early or Compensated Shock -Tachycardia, mild tachypnea, slightly delayed capillary refill (> 2 to 3 seconds), orthostatic changes in BP or pulse, and mild irritability • Late or Uncompensated Shock -Early compensatory mechanisms are not enough to meet the metabolic demands of the tissue -The child shows signs of brain, kidney, and cardiovascular compromise 21/4/2022 13
  14. 14. Types of shock • Hypovolumic shock • Septic shock • Cardiogenic shock • Obstructive shock • Distributive shock 21/4/2022 14
  15. 15. Case 1 • A 2 years old toddler presented with watery diarrhea w/c is non bloody of 5x per day of 3 days duration and non projectile non bilus vomiting of 5x ,today patient unable to wake for feeding no fever, abdominal pain but has decrease UOP PE lethargic BP 50/30 PR 200 weak Temp 37 capillary refill > 5sec ,mottled ,dry buccal mucosa • Is he in a shock? • What type? • Compensated or uncompensated? • What are your intervention? 21/4/2022 15
  16. 16. Hypovolemic shock • The most common cause of shock in children worldwide • Inadequate tissue perfusion from decreased intravascular volume as the result of fluid loss and/or inadequate fluid intake • Potential Etiology -Vomiting and/or diarrhea, Osmotic diuresis, Capillary leak, Hemorrhage, Inadequate fluid intake, Insensible losses 21/4/2022 16
  17. 17. • Clinical feature - initial presentation orthostatic hypotension, dry buccal mucosa ,poor skin turger and decreased UOP - depending on degree of dehydration may present with either normal or cool extremity - once hypotension develop CVS dysfunction and cardiac arrest can occur in minutes 21/4/2022 17
  18. 18. Timing Compensated Hypotensive Cardiac Arrest Possibly Hours Potentially Minutes
  19. 19. Managment • Airway and breathing -Supplemental oxygen with an initial inspired concentration of 100 percent -Early positive pressure ventilation and intubation should be performed in patients with airway compromise or impending respiratory failure 21/4/2022 19
  20. 20. Con’d • Control of hemorrhage -Direct manual pressure to control bleeding -sharp forceps body at site of bleeding or an amputation -compression at the nears vascular pressure points -Suturing, surgical staples, or scalp clips 21/4/2022 20
  21. 21. Con’d -Blood pressure tourniquet or Penrose drain tourniquet -reduction and splinting of long bone fracture -Place a pelvic stabilization device over the greater trochanter for suspected pelvic fracture 21/4/2022 21
  22. 22. Con’d • Vascular access -Adequate vascular access must be obtained for rapid infusion of fluid - Two peripheral intravenous catheters , that can be reliably placed typically suffice -Intraosseous cannulation should be performed if IV access cannot be established quickly 21/4/2022 22
  23. 23. Con’d • Fluid resuscitation -goal of fluid therapy is rapid restoration of intravascular volume -Children with hypovolemic shock should receive isotonic crystalloid 20 mL/kg per bolus over 5 to 10 min -Repeated, as needed, up to three times with in the first 30 – 60 minutes -Blood transfusion in patients with hypovolemic shock from hemorrhage may be required 21/4/2022 23
  24. 24. Con’d -Packed red blood cells should be given at 10 mL per kg over 1 to 2 hours to maintain a hemoglobin of 10 g per dL -Abnormalities in blood glucose and electrolyte measurements should be identified and treatment initiated 21/4/2022 24
  25. 25. 21/4/2022 25
  26. 26. 21/4/2022 26
  27. 27. 21/4/2022 27
  28. 28. Case 2 • A 4 yreas old child presented with foul smell diarrhea of 1 days duration 5-6 x a day associated with this he has intermittent abdominal pain and non projectile non bilus vomiting 2 episode a day ,decrease urine out put PE lethargic BP 60/40 PR 162 week RR 44 Tem 38,9 capillary refill > 4sec Anthropometry unaffected at emergency department resuscitated with NS 20 ml/kg 3x re assement show no change What are your next step in the management? 21/4/2022 28
  29. 29. Septic shock • SIRS - at least 2 of the following findings, 1 of which must be abnormal temperature or leukocyte count • (i) hyper- or hypothermia • (ii) tachycardia for age • (iii) tachypnea • (iv) Leukocyte count elevated or depressed for age 21/4/2022 29
  30. 30. • Sepsis - SIRS plus a suspected or proven infection • Severe Sepsis - sepsis plus two or more organ dysfunctions • Septic Shock - Sepsis plus cardiovascular organ dysfunction • Etiology -Could be bacterial, viral , fungal infections 21/4/2022 30
  31. 31. • Clinical feature - initial sign and symptom of sepsis include alteration in temp regulation, tachycardia and tachypnea - in the early stage ( hyper dynamic phase, low SVR,warm shock) - as septic shock progress cardiac out put fall lead to compensatory (high SVR and cold shock) 21/4/2022 31
  32. 32. Management • Airway and breathing • Treat hypoglycemia and hypocalcaemia • Intravenous fluid therapy -Initial therapy should begin with a bolus of 20 mL/kg of isotonic crystalloid solution, patients may require volumes of 60 -100 mL/kg or more in the first hour 21/4/2022 32
  33. 33. • Initial antimicrobial therapy - Should be initiated immediately after obtaining appropriate cultures within one hour of presentation -Each hour delay in antibiotic administration has been associated with an approximately 8 percent increase in mortality -Choice of antimicrobials can be complex and should consider the child's age, history, co morbidities, clinical syndrome, Gram stain data, and local resistance patterns 21/4/2022 33
  34. 34. Con’d -Coverage for enteric organisms should be added whenever clinical features suggest GU and/or gastrointestinal GI sources -Treatment for Pseudomonas species should be included for children who are immunosuppressed -Listeria monocytogenes and herpes simplex virus are important pathogens in infants ≤28 days of age -Ongoing antimicrobial therapy should be modified based upon culture results, including antimicrobial susceptibility and the patient’s clinical course 21/4/2022 34
  35. 35. Vasoactive medication 21/4/2022 35
  36. 36. 21/4/2022 36
  37. 37. Fluid refractory shock(15-60 min) • continue fluid resuscitation • initiate vasopressor then titrate to correct hypotension • normotensive shock dopamine 2-20mcg/kg/min, if poor perfusion continue dobutamine 2-20mcg/kg/min • warm shock (bounding pulse, rapid capillary refill) norepinephrine • cold shock (cold extremity, narrow pulse pressure, slow capillary refill) epinephrine 21/4/2022 37
  38. 38. Shock persist after vasopresor initiation (60min) • SVO2<70% cold shock ,transfuse if hg<10,optimize arterial oxygenation, ventilation, epinephrine • SVO2<70% normal Bp but poor perfusion, transfuse if hg< 10, consider • SVO2 >70% warm shock norepinephrine 0.1-2mcg/kg/min iv/io titrate to desired effect; consider vassopressin 0.2 -2mcg/kg/min and titrate to desired effect 21/4/2022 38
  39. 39. Fluid and catecholamine refractory shock • Hydrocortisone in stress doses (50mg/m 2 /day or 2 mg/kg per day, intermittent or continuous infusion is suggested • Should be discontinued when the patient becomes hemodynamically stable and no longer requires vasoactive medication administration 21/4/2022 39
  40. 40. • Extracorporeal Membrane Oxygenation - Consider ECMO for refractory pediatric septic shock and respiratory failure • Blood Products and Plasma Therapies -During resuscitation of Low superior vena cava oxygen saturation shock (<70%), hemoglobin Levels of 10 g/dL are targeted 21/4/2022 40
  41. 41. -After stabilization and recovery from shock and hypoxemia, a lower target (>7.0 g/dL) can be considered reasonable -Platelet transfusion -FFP transfused in patient with increased PT,PTT,INR 21/4/2022 41
  42. 42. Therapeutic end point • Heart rate normal for age • Capillary refill<2sec • Normal pulse quality • Warm extremity • Blood pressure normal for age • UOP > 1ml/kg/hr 21/4/2022 42
  43. 43. • Normal mental status • CVP>8MMHg • SvO2>70% • Decreasing lactate 21/4/2022 43
  44. 44. Case 3 • This is 10 yrs old a known cardiac patient (CRVHD,S.MS) on follow up for last 4 yr and taking lasix and spironolactne but discontinued the drug for last 1 week currently presented with worsening of sob and non projectile vomiting 2 episode for a day PE GA ASL in RD BP 70/50 PR 160 week RR 48 Tem 36.7 o2 85 % Capillary refill> 3 sec 21/4/2022 44
  45. 45. Con’d Anthropometry-moderate wasting RS-flaring of ala nase, sc/ic retraction - bilateral rales CVS- JVP is raised -feeble peripheral pulse -active and bulged precodium - grade 2 mid diastolic murmur at the apex Abdomen- hepatomegaly of 4cm BLCM,TLS is 12 cmCNS- irritable What type of shock? How do you intervene? 21/4/2022 45
  46. 46. Cardiogenic shock • Decrease cardiac out put and evidence tissue hypoxia with adequate circulation • Cardiac pump failure secondary to Poor myocardial function • CHD, cardiomyopathy, ischemia, arrhythmia, RHD(severe regurgitation and stenosis) postoperative complications of cardiac surgery and metabolic derangements 21/4/2022 46
  47. 47. • Cardiogenic – Decreased cardiac contractility caused by conditions such as primary myocardial injury, arrhythmias, cardiomyopathy, myocarditis, congenital heart disease with heart failure, sepsis, or poisoning 21/4/2022 47
  48. 48. • Cardiogenic shock — Cardiogenic shock results from pump failure, manifested physiologically as decreased systolic function and depressed cardiac output [10,11]. Cardiogenic shock is uncommon among children (table 2), as compared with adults, among whom ischemic heart disease is the major cause. • Cardiac causes may result from inadequate contractility or excessively fast or slow rhythms: • ●Cardiomyopathies – Primary myocardial injury is an uncommon cause of shock in children. Causes of myopathic pump failure include familial, infectious, infiltrative, and idiopathic cardiomyopathies. Prolonged ischemia, cardiopulmonary bypass, and the myocardial depression of late sepsis all can contribute to secondary myocardial dysfunction. • ●Arrhythmias – Structural heart disease, drug intoxications, and hypothermia are leading causes of arrhythmia in children. Both atrial and ventricular arrhythmias can cause cardiogenic shock. 21/4/2022 48
  49. 49. • •Ventricular fibrillation and pulseless ventricular tachycardia abolish cardiac output, while diminished ventricular filling time during ventricular tachycardia decreases preload and stroke volume substantially. (See "Management and evaluation of wide QRS complex tachycardia in children".) • •Prolonged unrecognized supraventricular tachycardia (as can occur with the initial presentation for infants) can decrease cardiac output. (See "Clinical features and diagnosis of supraventricular tachycardia in children".) • •Bradyarrhythmias and complete heart block can result in shock caused by chronotropic (heart rate) insufficiency, independent of stroke volume. (See "Bradycardia in children".) 21/4/2022 49
  50. 50. Blunt cardiac injury • Myocardial contusion • Traumatic aneurysm • Traumatic septal defect • Chamber rupture • Valvular rupture 21/4/2022 50
  51. 51. • Congenital heart disease • Pulmonary hypotension • Severe heart failure secondary to congenital heart disease • Postoperative cardiac surgery 21/4/2022 51
  52. 52. Drug toxicity • Beta blockers • Barbiturates • Chemotherapeutic agents • Calcium channel blockers • Radiation 21/4/2022 52
  53. 53. • Metabolic derangements • Acidosis • Hyperkalemia • Hypocalcemia • Congenital organic acidemias • Late septic shock • Hypoxic or anoxic/ischemic injury • Hypothermia • Viral myocarditis • Cardiomyopathies • Dilated cardiomyopathies • Infiltrative cardiomyopathies • Mucopoylsaccharidosis • Glycogen storage diseases • Ischemic heart disease • Anomalous left coronary artery • Kawasaki disease • Myocardial infarction • Thyrotoxicosis • Pheochromocytoma 21/4/2022 53
  54. 54. • Mortality exceeds 50% and management is focused on a rapid diagnosis of cardiogenic shock, restoration of coronary blood flow through early revascularization, complication management, and maintenance of end- organ homeostasis. Besides revascularization, inotropes and vasodilators are potent medical therapies to assist the failing heart. 21/4/2022 54
  55. 55. • Cardiogenic shock — A history of heart disease, an abnormal cardiac examination, and/or worsening clinical condition with fluid resuscitation are suggestive of cardiogenic shock. Additional findings include tachycardia out of proportion to fever or respiratory distress, cyanosis unresponsive to oxygen, raised jugular venous pulsations, and absent femoral pulses. Cardiogenic shock is less common than other forms of shock in children. Early consultation with a pediatric cardiologist or intensivist is recommended. (See "Initial evaluation of shock in children", section on 'Clinical classification of shock'.) • Management issues include the following: • ●Cardiogenic shock (as from myocarditis or a toxic ingestion) should be considered for any child without a readily apparent cause for shock whose condition worsens with fluid therapy (table 10). (See "Clinical manifestations and diagnosis of myocarditis in children", section on 'Clinical manifestations'.) • ●Some children with poor cardiac function may also be volume depleted. Fluid should be administered slowly and in boluses of 5 to 10 mL/kg. • ●Treatment with dobutamine or phosphodiesterase enzyme inhibitors can improve myocardial contractility and reduce systemic vascular resistance (afterload). (See "Use of vasopressors and inotropes", section on 'Dobutamine'.) • ●Cardiac arrhythmias (eg, supraventricular or ventricular tachycardia) should be addressed prior to fluid resuscitation (algorithm 3). 21/4/2022 55
  56. 56. Con’d • Clinical presentation - symptom depend on age infant; poor feeding, appétit loss and can quickly progress to lethargy , -older child fatigue ,difficulty of breathing or chest pain , as shock progress may experience syncope or AMS - tachycardia, tacypnea, week pulse, high JVP ,crackle, hepatomegally, coma 21/4/2022 56
  57. 57. • Cardiogenic shock – History of heart disease (eg, corrected congenital heart disease or cardiomyopathy), history of palpitations, signs of heart failure (eg, pulmonary rales, hepatomegaly, gallop rhythm, distended jugular veins), or arrhythmia • However, a patient may have more than one type of shock (such as an infant with cardiogenic shock from supraventricular tachycardia who is also hypovolemic because he has been unable to drink or a child with underlying cardiomyopathy who is septic). 21/4/2022 57
  58. 58. Management • Initial resuscitation - stabilizing the airway ,breathing, circulation with establishment of vascular access - continues monitoring of vital signs, pulse oximetry saturation -chest compression indicated for bradicardia with poor perfusion 21/4/2022 58
  59. 59. Con’d • In low cardiac output state with hypotension -optimization of preload by giving small NS bolus 5- 10ml /kg, with careful monitoring with hepatomegaly and basal crepitation -dopamine 10mcg/kg/min and/or doubutamine 10- 15mcg/kg/min infusion - mechanical ventilation if patient in respiratory distress or critically ill 21/4/2022 59
  60. 60. 21/4/2022 60 • cardiogenic shock is characterized by a decrease in myocardial contractility, and presents a high mortality rate. Inotropic and vasopressor agents have been recommended and used for several years in the treatment of patients in shock, but they remain controversial. Despite its beneficial effect on myocardial contractility, the side effects of inotropic therapy (arrhythmias and increased myocardial oxygen consumption) may be associated with increased mortality. The pharmacodynamics of different inotropic agents suggest benefits in specific situations, but these differences have not been reflected in reduced mortality in most studies, making it difficult to formulate recommendations
  61. 61. • In patients with cardiogenic shock, norepinephrine is preferred over dopamine as the first-line vasopressor because a subgroup analysis from a randomized trial found that patients with cardiogenic shock who received dopamine had a higher mortality than those who received norepinephrine [28]. In addition, dysrhythmias were more common in the dopamine group. 21/4/2022 61
  62. 62. • Results: Literature was assessed to review the use of inotropes and vasopressors in CS. Dopamine and adrenaline were associated with increased mortality and arrhythmias. Dobutamine was associated with an improvement in cardiac output, at the determinant of causing arrhythmias. Conversely, noradrenaline was associated with a lower likelihood of arrhythmias and most importantly decreased mortality in CS. Compared to other inotropes, levosimendan appears to have a better safety profile and is associated with decreased mortality in CS, particularly when combined with a vasopressor. Our literature review suggests that treatment combination of the inotrope levosimendan with the vasopressor noradrenaline may be the most effective management option in CS. 21/4/2022 62
  63. 63. • For suspected cardiogenic shock, children who are also hypovolemic should receive a smaller isotonic crystalloid fluid bolus of 5 to 10 mL/kg, infused over 10 to 20 minutes. This approach decreases the likelihood of exacerbating heart failure. cck 21/4/2022 63
  64. 64. Con’d • In low cardiac output with normal blood pressure -Frusamide infusion 0.05-0.1mg/kg/h to be added -Add milirnon 0.1 -1mcg/kg/min 21/4/2022 64
  65. 65. Con’d • Increased afterload state -characterized by normalized HR, good central pulse, weak peripheral pulse, cold periphery, BP normal to high, hyperlactemia -increase infusion rate of milirnon 21/4/2022 65
  66. 66. Con‘d • After milirnon infusion ,tachycardia, good pulse, warm periphery, decrease UOP, slightly low BP and hyperlactemia consider hypovlumia and administer 5- 10ml/kg fluid bolus • When optimal cardiac out put is achieved, good normal pulse, warm extremity, good UOP, normal BP and normal lactate maintain the same inotropic support 21/4/2022 66
  67. 67. Con’d - start weaning from ventilation in a stepwise manner and plan extubation - after extubation slow and gradual inotrope tapering should be initiated after adding enalapril or captopril - digoxin can be considered if there is reduced contractility or for rate control 21/4/2022 67
  68. 68. Con’d • Treatment of precipitating factor and specific management of the underling cause - correction of arrhythmia - correction of anemia - treatment of underling infection - correction of electrolyte imbalance 21/4/2022 68
  69. 69. Case 4 • A 10 year old child with presented with sudden onset of difficulty of breathing , lip and tongue swelling of1 hour,he also has purities and strider at rest , 3 hours before while he was playing at his yard he was stung on the forearm by bee, his parent immediately placed ice over the area PE ASL in RD,irritable BP 60/40 RR40 tem 36.7 o2 70% lip,tonge uvula swelling marked decrease air entry How do you manage? 21/4/2022 69
  70. 70. Distributive shock • Caused by inadequate vasomotor tone, which leads to capillary leak and maldistribution of fluid into the interstitium • Abnormal vasodilatation and decreased SVR • Significant decreases in both preload and after load 21/4/2022 70
  71. 71. • Distributive shock — Distributive shock is notable for a marked decrease in systemic vascular resistance. Thus, vasopressors are frequently employed along with fluid therapy, depending upon the underlying etiology as follows 21/4/2022 71
  72. 72. • Distributive shock – Distributive shock physiologically refers to a condition in which systemic vascular resistance is initially decreased. It may occur as the result of sepsis, anaphylaxis, or neurologic injury. (See "Pathophysiology and classification of shock in children", section on 'Distributive shock'.) • With sepsis and anaphylaxis, volume depletion may also develop because of losses related to the underlying infection (septic shock), or inflammatory cascade (anaphylaxis). Both processes are associated with increased capillary permeability with loss of plasma from the intravascular space into the tissues. Myocardial dysfunction can also contribute to poor tissue perfusion. • In septic shock, abnormal distribution of blood flow as the result of changes in vasomotor tone causes inappropriate tissue perfusion (such as decreased splanchnic circulation with increased flow to skin and muscle). Systemic vascular resistance (SVR) may be low, producing increased blood flow to skin and a wide pulse pressure (warm shock) or SVR may be increased, in which case, blood flow to skin is decreased and the pulse pressure is narrow (cold shock). (See "Systemic inflammatory response syndrome (SIRS) and sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.) 21/4/2022 72
  73. 73. • Anaphylactic shock – A history of allergies and/or the presence of stridor, wheezing, urticaria, or facial edema suggest anaphylaxis. Children with possible anaphylaxis should receive intramuscular epinephrine, intravenous or intramuscular diphenhydramine, and steroids, in addition to rapid infusions of normal saline. Wheezing should be treated with nebulized albuterol. Patients with cardiovascular collapse or those that respond poorly to intramuscular epinephrine may require epinephrine intravenously (table 5 and table 8 and table 9). (See 'Goal-directed approach' above and "Anaphylaxis: Emergency treatment", section on 'Immediate management'.) • ● 21/4/2022 73
  74. 74. • Neurogenic shock – Neurogenic shock refers to hypotension, usually with bradycardia, attributed to interruption of autonomic pathways in the spinal cord causing decreased vascular resistance. Patients with traumatic spinal cord injury may also suffer from hemodynamic shock related to blood loss and other complications. An adequate blood pressure is believed to be critical in maintaining adequate perfusion to the injured spinal cord and thereby limiting secondary ischemic injury. Appropriate mean arterial pressure for age should be maintained using intravenous fluids, transfusion, and pharmacologic vasopressors as needed. Bradycardia caused by cervical spinal cord or high thoracic spinal cord disruption may require external pacing or administration of atropine. (See "Acute traumatic spinal cord injury", section on 'Cardiovascular complications'.) 21/4/2022 74
  75. 75. • Etiology -anaphylaxis -Neurologic: loss of sympathetic vascular tone secondary to spinal cord or brainstem injury -Drugs, Sepsis, hypoxia, poisoning 21/4/2022 75
  76. 76. Anaphylaxis • Diagnosing criteria for anaphylaxis • Highly likely when any one of the 3 criteria met 1 acute onset of illness( generalized hives,itching,edema of lips and tongue or uvula) and at least one of the following -Respiratory symptom - decreased BP or 21/4/2022 76
  77. 77. 2 two of the following that occur rapidly after exposure to a likely allergen - skin or mucosal symptom - respiratory symptom, -Decreased BP - GI symptom 3 Decreased BP after exposure to known allergen 21/4/2022 77
  78. 78. • Diagnosis is made clinically: • The most common signs and symptoms are cutaneous (eg, sudden onset of generalized urticaria, angioedema, flushing, pruritus). However, 10 to 20% of patients have no skin findings. • Danger signs: Rapid progression of symptoms, evidence of respiratory distress (eg, stridor, wheezing, dyspnea, increased work of breathing, retractions, persistent cough, cyanosis), signs of poor perfusion, abdominal pain, vomiting, dysrhythmia, hypotension, collapse 21/4/2022 78
  79. 79. • the first and most important therapy in anaphylaxis is epinephrine. There are NO absolute contraindications to epinephrine in the setting of anaphylaxis. • Airway: Immediate intubation if evidence of impending airway obstruction from angioedema. Delay may lead to complete obstruction. Intubation can be difficult and should be performed by the most experienced clinician available. Cricothyrotomy may be necessary. • IM epinephrine (1 mg/mL preparation): Epinephrine 0.01 mg/kg should be injected intramuscularly in the mid-outer thigh. For large children (>50 kg), the maximum is 0.5 mg per dose. If there is no response or the response is inadequate, the injection can be repeated in 5 to 15 minutes (or more frequently). If epinephrine is injected promptly IM, patients respond to one, two, or at most, three injections. If signs of poor perfusion are present or symptoms are not responding to epinephrine injections, prepare IV epinephrine for infusion (see below). 21/4/2022 79
  80. 80. • Place patient in recumbent position, if tolerated, and elevate lower extremities. • Oxygen: Give 8 to 10 L/minute via facemask or up to 100% oxygen, as needed. • Normal saline rapid bolus: Treat poor perfusion with rapid infusion of 20 mL/kg. Re-evaluate and repeat fluid boluses (20 mL/kg), as needed. Massive fluid shifts with severe loss of intravascular volume can occur. Monitor urine output. • Albuterol: For bronchospasm resistant to IM epinephrine, give albuterol 0.15 mg/kg (minimum dose: 2.5 mg) in 3 mL saline inhaled via nebulizer. Repeat, as needed. 21/4/2022 80
  81. 81. • Treatment of refractory symptoms: • Epinephrine infusion¶: In patients with inadequate response to IM epinephrine and IV saline, give epinephrine continuous infusion at 0.1 to 1 mcg/kg/minute, titrated to effect. • Vasopressors¶: Patients may require large amounts of IV crystalloid to maintain blood pressure. Some patients may require a second vasopressor (in addition to epinephrine). All vasopressors should be given by infusion pump, with the doses titrated continuously according to blood pressure and cardiac rate/function monitored continuously and oxygenation monitored by pulse oximetry. 21/4/2022 81
  82. 82. Management • Airway management -Supplemental oxygen, 6 to 8 liters by facemask, up to 100 percent, should be administered - Intubation, cricothyroidotomy • Fluid management -Children should receive N/S 20 mL/kg each over 5 to 10 minutes, and repeated as needed 21/4/2022 82
  83. 83. • Epinephrine - is the first choice in anaphylaxis -recommended dose is 0.01 mg/kg (up to 0.5 mg per dose), injected intramuscularly into the mid- anterolateral thigh -may be repeated at 5 to 15 minute intervals 21/4/2022 83
  84. 84. Adjuvant therapy • Antihistamine -relieve itch and hives • Bronchodilator - For the treatment of bronchospasm not responsive to epinephrine • Corticosteroid - is to prevent the biphasic or protracted reactions 21/4/2022 84
  85. 85. Case 5 • A 4 year old child is brought to the ED after sustained blunt chest trauma on P/E he is restless but conscious, no bleeding from any area ,v/s BP is60/40 PR =60 full radial T=370c RR=40 o2 70% Capillary refill is <2sec , resp trachea shifted to left ,hyperesonant right chest cvs distended neck vein how do you approach ? 21/4/2022 85
  86. 86. Obstructive shock • Decreased cardiac Output secondary to direct impediment to right or left sided heart outflow or restriction of all cardiac chambers • Etiology Tension pneumothorax, pericardial tamponade, Pulmonary embolism, anterior mediastinal masses, Critical COA 21/4/2022 86
  87. 87. • Obstructive shock — Causes of obstructive shock (eg, tension pneumothorax, cardiac tamponade, hemothorax, pulmonary embolism, or ductal- dependent congenital heart defects) require specific interventions to relieve the obstruction to blood flow. 21/4/2022 87
  88. 88. • Life-threatening conditions — Life-threatening conditions that warrant prompt intervention and can be associated with shock include: • ●Angioedema with upper airway obstruction – Children with upper airway obstruction from anaphylaxis should receive epinephrine (table 5). Intubation or a surgical airway may be necessary for patients with complete upper airway obstruction or with no response to epinephrine. (See "Emergency evaluation of acute upper airway obstruction in children", section on 'Determining the cause of upper airway obstruction' and "The difficult pediatric airway", section on 'Approach to the failed airway'.) • ●Tension pneumo- or hemothorax – Tension pneumo- or hemothorax typically presents with severe respiratory distress, asymmetric breath sounds, and poor perfusion and must be promptly decompressed. (See "Prehospital care of the adult trauma patient", section on 'Needle chest decompression' and "Placement and management of thoracostomy tubes".) • ●Cardiac tamponade – Patients with respiratory distress, poor perfusion, muffled heart tones, pulsus paradoxus, hepatomegaly, and/or distended neck veins may have obstructive shock from cardiac tamponade. Fluid must be drained as quickly as possible, preferably in the operating room. (See "Emergency pericardiocentesis", section on 'Technique overview'.) 21/4/2022 88
  89. 89. • ●Ductal dependent congenital heart defects – Infants under 28 days of age with a high clinical suspicion for ductal-dependent congenital heart defects should receive prostaglandin E1 (also known as alprostadil). (See "Approach to the ill-appearing infant (younger than 90 days of age)", section on 'Initial stabilization'.) • ●Pulmonary embolism – Treatment for massive pulmonary embolism consists of supportive care, antithrombotic therapy (unless otherwise contraindicated, as with patients who have had recent surgery), and, in selected patients, thromboembolectomy. (See "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults", section on 'Embolectomy' and "Venous thrombosis and thromboembolism in children: Treatment, prevention, and outcome", section on 'Approach to treatment'.) • ●Arrhythmia – Poor perfusion as a result of brady- or tachyarrhythmias requires immediate medical attention as follows: • •Supraventricular tachycardia or ventricular tachycardia with poor perfusion should be treated with synchronized cardioversion (table 7). (See "Management and evaluation of wide QRS complex tachycardia in children", section on 'Unstable patient'.) • •Children with bradycardia who are not hypoxic should receive epinephrine (or atropine if increased vagal tone or primary AV block is suspected) and may require cardiac compressions (algorithm 4). (See "Pediatric advanced life support (PALS)", section on 'Bradycardia algorithm'.) 21/4/2022 89
  90. 90. • Obstructive shock – Obstructive shock describes physical obstruction of systemic blood flow from the heart which causes abrupt impairment of cardiac output (table 1). Causes of obstructive shock include cardiac tamponade, tension pneumo- or hemothorax and massive pulmonary embolism. Infants with ductal-dependent congenital heart lesions, such as coarctation of the aorta and hypoplastic left ventricle syndrome, may also present in shock when the ductus arteriosus closes during the first few weeks of life. Conditions that cause obstructive shock must be recognized quickly because they generally require specific treatment. (See "Pathophysiology and classification of shock in children", section on 'Obstructive shock' and "Approach to the ill-appearing infant (younger than 90 days of age)", section on 'Initial stabilization'.) 21/4/2022 90
  91. 91. 21/4/2022 91
  92. 92. • Children with severe respiratory distress and signs of circulatory compromise may have obstructive shock 21/4/2022 92
  93. 93. Management • Fluid resuscitation may be briefly temporizing in maintaining cardiac output • The primary insult must be immediately addressed -Pericardiocentesis for pericardial effusion -Pleurocentesis or chest tube placement for pneumothorax -Thrombectomy/thrombolysis for Pulmonary embolism 21/4/2022 93
  94. 94. Management of shock in SAM • Considered to have shock if he/she is lethargic or unconscious and has cold hands plus either - slow capillary refill (longer than three seconds), or - weak, fast or absent radial or femoral pulses 21/4/2022 94
  95. 95. • Severe malnutrition – Intravenous fluid resuscitation in children with severe malnutrition and signs of shock is controversial [11]. Sunken eyes, lethargy, and tenting may occur from malnutrition alone and can cause clinicians to overestimate the degree of dehydration [12]. Some experts believe that malnutrition causes sodium and water retention, overexpansion of the extracellular fluid, and myocardial dysfunction [11,13-15]. Thus, rapid administration of intravenous fluids to infants and children who do not have fluid depletion or physiologic changes associated with severe malnutrition or both may risk fluid overload, heart failure, and pulmonary edema and is not recommended by the World Health Organization (WHO) [12,16]. • However, evidence suggests that the WHO recommendations for fluid resuscitation in severely malnourished may be too restrictive. For example, in an observational study of fluid resuscitation in 149 severely malnourished children with cholera and severe dehydration, infusion of approximately 20 mL/kg per hour of an isotonic saline solution over four to six hours was not associated with heart failure in any patient, and all patients survived [17]. Furthermore, in a clinical trial of 61 children with severe malnutrition accompanied by decompensated shock in the majority of patients, administration of 30 to 40 mL/kg of crystalloid fluids over two hours failed to reverse shock in over half of patients and was accompanied by high mortality [11]. • Thus, pending further study, some experts suggest that severely malnourished children receive fluid resuscitation with careful reassessment according to the WHO guidelines for children with shock and no signs of malnutrition. 21/4/2022 95
  96. 96. If the child in shock • Give O2 for infant 0.5l/min and for older children 1-2 l/min • Give sterile 10% glucose 5ml/kg by iv • Keep child warm • Give iv fluid -Infuse IV fluid at 15ml/kg over 1 hour - Repeat the same amount of IV fluids for another hour if child improving 21/4/2022 96
  97. 97. • After two hours of IV fluids, switch to oral or NG rehydration with ReSoMal -Give 5-10 ml/kg ReSoMal in alternate hours with F-75 for up to 10 hours or until fully rehydrated -If the respiratory rate and pulse rate increase and child is gaining weight, stop the IV rehydration and assume septic or cardiogenic shock 21/4/2022 97
  98. 98. • If no improvement after 1st hour of iv fluids ,then assume septic shock • Then transfuse 10ml/kg slowly over 3 hours • If there are signs of heart failure, give packed cells 21/4/2022 98
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  100. 100. • DKA: diabetic ketoacidosis. • * For possible cardiogenic shock with hypovolemia, give 5 to 10 mL/kg of isotonic fluids (eg, normal saline or Ringers lactate), infused over 10 to 20 minutes. Evaluate target endpoints and slowly give another 5 to 10 mL/kg if there has been improvement or no change. For patients with diabetic ketoacidosis, give 10 mL/kg of isotonic fluids over one hour. • ¶ Such as inotropes or vasodilators. For newborns, prostaglandin E1. Refer to UpToDate topics on management of cardiogenic shock in children and management of neonates with cyanotic heart disease. • Δ For patients with DKA who do not improve with 20 mL/kg, look for another cause of shock before administering additional crystalloid. For possible cardiogenic shock, slowly give another 5 to 10 mL/kg if there has been improvement or no change. 21/4/2022 100
  101. 101. • MONITORING — Effective management of children with shock requires frequent adjustment of therapeutic interventions based upon continuous hemodynamic monitoring and assessment of end organ perfusion (brain, kidneys, and skin). • Monitoring should include continuous noninvasive measurement of heart rate and pulse oximetry with frequent measurement of blood pressure. In addition to these parameters, the following clinical features should also be observed before and after each fluid bolus (see 'Physiologic indicators and target goals' above): • ●Quality of central and peripheral pulses • ●Skin perfusion (as indicated by temperature and capillary refill) • ●Mental status • ●Auscultation of lung and heart sounds • ●Palpation of liver edge (to identify hepatomegaly as a sign of heart failure) 21/4/2022 101
  102. 102. • More aggressive monitoring may be necessary for children who do not improve with fluid resuscitation. (See 'Goal-directed approach' above.) • Interventions to consider include: • ●A urinary catheter should be placed to monitor urine output. • ●Children receiving vasoactive infusions should generally have arterial pressure monitoring after initial resuscitation. Placement of intraarterial catheters may occur in the emergency department or intensive care unit, depending upon resources. (See "Arterial puncture and cannulation in children", section on 'Arterial cannulation'.) • ●Children with fluid and catecholamine-resistant shock should be expeditiously transferred to intensive care units where central venous pressure (CVP) and central venous oxygen saturation (ScvO2) can be monitored. CVP is an indication of preload. A measurement of <8 mmHg suggests that fluid resuscitation has been inadequate. • ●ScvO2 measurements provide information regarding oxygen supply and consumption at the tissue level as an indication of perfusion. Experts recommend a target ScvO2 of >70 percent as an indication of adequate perfusion [2]. In adults, lactate clearance is considered a reasonable alternative to measurement of ScvO2, but data in children are limited. (See "Evaluation and management of suspected sepsis and septic shock in adults".) 21/4/2022 102
  103. 103. • PITFALLS — The management of children with shock is challenging. Some pitfalls include: • ●Failure to recognize nonspecific signs of compensated shock (ie, unexplained tachycardia, abnormal mental status, or poor skin perfusion) • ●Inadequate monitoring of response to treatment • ●Inappropriate volume for fluid resuscitation (usually too little for children with sepsis or hypovolemic shock, but possibly too much for those with cardiogenic shock) • ●Failure to reconsider possible causes of shock for children who are getting worse or not improving • ●Failure to recognize and treat obstructive shock 21/4/2022 103
  104. 104. prognosis • In septic shock, mortality rates are; -As low as 3% in previously healthy children -And 6–9% in children with chronic illness • With early recognition and therapy, the mortality rate for pediatric shock continues to improve • Shock and MODS remain one of the leading causes of death in infants and children 21/4/2022 104
  105. 105. Reference • Nelson 2021 edition • Up-to-date • Pediatrics emergency management protocol 2021 2nd edition • SAM gridline 2020 3rd edition • JAMMA and PUBMED pediatrics journal 21/4/2022 105
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  107. 107. • Distributive – Decreased vascular resistance due to vasodilation caused by conditions such as sepsis, anaphylaxis, or acute injury to the spinal cord or brain • ●Cardiogenic – Decreased cardiac contractility caused by conditions such as primary myocardial injury, arrhythmias, cardiomyopathy, myocarditis, congenital heart disease with heart failure, sepsis, or poisoning • ●Obstructive – Increased vascular resistance caused by conditions such as congenital heart disease with ductal dependent lesions (eg, hypoplastic left heart), or acquired obstructive conditions (eg, pneumothorax, cardiac tamponade, or massive pulmonary embolism) 21/4/2022 107
  108. 108. • Hypotensive hypovolemic or distributive shock – We recommend that children with hypotensive hypovolemic or distributive shock (as from gastrointestinal losses, traumatic hemorrhage, sepsis, or anaphylaxis), receive 20 mL/kg per bolus of isotonic crystalloid, such as normal saline or Ringer's lactate solution, infused over 5 to 10 minutes and repeated, as needed, up to four times in patients without improvement and no signs of fluid overload [2,6,7]. Additional therapies, such as blood transfusion in patients with hypovolemic shock from hemorrhage or vasoactive drug therapy and corticosteroid administration in patients with septic shock may be required depending upon the response to fluid administration. (See 'Hypovolemic shock' below and 'Distributive shock' below.) • Observational studies of rapid fluid resuscitation as a component of goal-directed therapy and in conjunction with other critical care interventions such as prophylactic endotracheal intubation with mechanical ventilation and close monitoring by pediatric critical care specialists has been associated with a marked decrease in mortality, especially in children with hypotensive septic shock. (See 'Evidence for goal-directed therapy in children' below.) • Techniques to rapidly deliver intravenous fluid include gravity, applying pressure directly to the bag of fluid with an inflatable device, delivering aliquots of fluid using a large syringe that is refilled through a three-way stopcock attached to the bag (the "push-pull" method) or use of rapid infusion pumps designed to deliver high volumes of warmed fluids or blood. Gravity alone is likely insufficient to deliver 20 mL/kg over 5 to 10 minutes. This was demonstrated in a randomized trial that compared the rate at which fluid could be delivered to 57 children requiring fluid resuscitation using gravity, an inflatable pressure bag, or a "push-pull" method [8]. The median volume of fluid delivered over five minutes by gravity was 6.2 mL/kg, in comparison to 20.9 mL/kg for the pressure bag and 20.2 mL/kg for the "push-pull" method. These differences remained significant after controlling for intravenous catheter gauge, age, and weight. • ● 21/4/2022 108
  109. 109. • Compensated hypovolemic or distributive shock – We suggest that children with compensated hypovolemic or distributive shock receive 20 mL/kg per bolus of isotonic crystalloid, such as normal saline or Ringer's lactate solution over 5 to 20 minutes. Patients should be closely monitored during fluid administration. Additional fluid boluses may be indicated depending upon the patients’ response. Evidence suggests that overly aggressive fluid bolus may be harmful in selected patients, including those with cardiogenic shock, DKA, syndrome of inappropriate antidiuretic hormone secretion, severe malnutrition, or, in resource-limited settings, severe febrile illness in the absence of dehydration or hemorrhage. (See 'Risks' below.) 21/4/2022 109
  110. 110. • Cardiogenic shock – For suspected cardiogenic shock in patients with signs such as a gallop rhythm, pulmonary rales, jugular venous distension, or hepatomegaly, a smaller isotonic crystalloid fluid bolus of 5 to 10 mL/kg, infused over 10 to 20 minutes decreases the likelihood of exacerbating heart failure 21/4/2022 110
  111. 111. • Cardiogenic shock – Although many children with cardiogenic shock have some degree of hypovolemia, fluids should be administered slowly and in boluses of 5 to 10 mL/kg in such patients to avoid worsening myocardial insufficiency and pulmonary edema. Clinical findings of cardiogenic shock include gallop rhythm, jugular venous distension, pulmonary rales, and hepatomegaly. 21/4/2022 111
  112. 112. • EARLY GOAL-DIRECTED THERAPY — Early goal-directed therapy for shock refers to an aggressive systematic approach to resuscitation targeted to improvements in physiologic indicators of perfusion and vital organ function within the first six hours. Targeted interventions are determined by degree of illness and response to treatment within the first hour of care. This approach has been most strongly promoted for children with septic shock. (See "Septic shock in children: Rapid recognition and initial resuscitation (first hour)", section on 'Resuscitation'.) • Early goal-directed therapy for septic shock in adults is discussed in detail separately. (See "Evaluation and management of suspected sepsis and septic shock in adults".) • Physiologic indicators and target goals — Physiologic indicators that should be targeted during therapy (with goals in parentheses) include [2]: • ●Blood pressure (systolic pressure at least fifth percentile for age: 60 mmHg <1 month of age, 70 mmHg + [2 x age in years] in children 1 month to 10 years of age, 90 mmHg in children 10 years of age or older) • ●Quality of central and peripheral pulses (strong, distal pulses equal to central pulses) • ●Skin perfusion (warm, with capillary refill <2 seconds) • ●Mental status (normal mental status) • ●Urine output (≥1 mL/kg per hour, once effective circulating volume is restored) 21/4/2022 112
  113. 113. • Heart rate is an important physiologic indicator of circulatory status. For children with shock, tachycardia is often a compensatory response to poor tissue perfusion. In this situation, a decrease in heart rate with fluid therapy can be a valuable indicator of improved perfusion in response to treatment (table 2). However, many other factors (ie, fever, drugs, hypoxia, and anxiety) influence heart rate. In addition, an abnormal heart rate may be the direct result of the cause of shock (as with myocarditis or beta blocker ingestion). Although trends in response to treatment should be carefully monitored, specific target goals for heart rate are difficult to define and may not be useful. 21/4/2022 113
  114. 114. • Cardiogenic shock – For suspected cardiogenic shock in patients with signs such as a gallop rhythm, pulmonary rales, jugular venous distension, or hepatomegaly, a smaller isotonic crystalloid fluid bolus of 5 to 10 mL/kg, infused over 10 to 20 minutes decreases the likelihood of exacerbating heart failure. (See 'Cardiogenic shock' below.) 21/4/2022 114
  115. 115. • Cardiogenic shock – Although many children with cardiogenic shock have some degree of hypovolemia, fluids should be administered slowly and in boluses of 5 to 10 mL/kg in such patients to avoid worsening myocardial insufficiency and pulmonary edema. Clinical findings of cardiogenic shock include gallop rhythm, jugular venous distension, pulmonary rales, and hepatomegaly 21/4/2022 115
  116. 116. • Choice of fluid — Fluid therapy for children with shock should begin with isotonic crystalloid, such as normal saline or Lactated Ringers solution, as supported by the following evidence: • ●Randomized trials and meta-analyses have failed to consistently demonstrate a difference between colloid and crystalloid for the treatment of shock in adults. (See "Treatment of hypovolemia (dehydration) in children", section on 'Crystalloid versus colloid' and "Treatment of hypovolemia or hypovolemic shock in adults", section on 'Colloid versus crystalloid'.) • ●For children, randomized trials comparing colloid with crystalloid for hypotensive newborns and for children with dengue shock syndrome have not demonstrated a difference between the solutions [19-22]. • ●Colloid solutions are more expensive and patients may develop adverse reactions to them. • ●Many patients in shock are hyperglycemic. Although identification and treatment of hypoglycemia is very important, the rapid infusion and large amounts of bolus fluids to treat shock necessitate exclusion of glucose from the resuscitation fluids. 21/4/2022 116
  117. 117. • Fluid administration — Limited evidence exists concerning the optimal amount and rate of fluid administration for children with shock. Several studies support the use of isotonic crystalloid fluid bolus (ie, normal saline or Ringers Lactate) as a component of goal-directed therapy for shock other than obstructive shock (eg, tension pneumothorax, pericardial tamponade, or massive pulmonary embolus). However, aggressive fluid resuscitation may be harmful for children who are not hypovolemic or have compensated shock with certain comorbidities (eg, cardiac disease, diabetic ketoacidosis [DKA], syndrome of inappropriate antidiuretic hormone secretion [SIADH], severe malnutrition, or malaria). Patients with obstructive shock should receive emergent correction of the underlying cause (eg, needle or chest tube thoracostomy for tension pneumothorax or pericardiocentesis for cardiac tamponade). Neonates with ductal dependent lesions and circulatory collapse may also be hypovolemic. However, primary treatment should focus on reopening the ductus arteriosus with prostaglandin E1 (alprostadil). (See 'Evidence for goal-directed therapy in children' below and 'Risks' below and 'Obstructive shock' below.) 21/4/2022 117
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  119. 119. THANK YOU 21/4/2022 119

Notas do Editor

  • Early recognition & timely intervention are critical to halting the progression from compensated shock to hypotensive shock to cardiopulmonary failure & arrest