CẤP CỨU

1. Tiếp cận bệnh nhi sốc

2. Definition
• Pediatric shock is a condition that occurs when the delivery of oxygen
and nutrients to the organs and tissues of the body is compromised.

3. Type and Severity
• Type:
- Hypovolemic Shock
- Obstructive Shock
- Distributive/Septic Shock
- Cardiogenic Shock
• Severity:
- Compensated Shock: Normal systolic BP, decreased level of consciousness,
cool extremities with delayed capillary refill, and faint or non-palpable distal
pulses
- Hypotensive Shock: Hypotension with signs of shock

4. Understanding Shock
Shock results from a failure in one or more of the
components involved in the tissue oxygen delivery process.
• Sufficient cardiac output that provides enough oxygen saturated
blood to meet the demands of the tissues and organs of the
body. (click for full explanation)
• Adequate hemoglobin concentration with sufficiently oxygen
saturated hemoglobin. (click for full explanation)
• Proper distribution of the blood to appropriate organs and
tissues. (click for full explanation)

5. Cardiac output
• CO = HR x SV. Three factors that influence stroke volume
are preload, afterload, and contractility.
• Inadequate preload: severe dehydration, hemorrhage, or vasodilation.
• Inadequate contractility: myocarditis, drug or toxin overdose, and
possibly hypoglycemia.
• Increase in afterload (rarely) caused by severe pulmonary
hypertension and congenital aortic abnormalities

6. • Cardiac output has a direct effect upon the progression or
improvement of shock.
• Cardiac output = stroke volume (preload, afterload, and contractility)
x heart rate
• Summary sentence: If you change heart rate, preload, afterload, or
contractility, you alter cardiac output.

7. Recognition of Pediatric Shock
• Tachycardia:
• Increased Systemic Vascular Resistance (Vasoconstriction)
— slowed capillary refill,
— cool, pale, and mottled skin
— weak peripheral pulses
— decreased urine output
• Increased Cardiac Contractility:
• Blood Pressure

8. Blood pressure
• In children, the compensatory mechanism of increased systemic
vascular resistance can be very effective at maintaining systolic
blood pressure. However, because of the increase in systemic
vascular resistance (SVR), diastolic pressure is typically elevated. The
increased SVR causes a narrowed pulse pressure which is the
difference between the systolic and diastolic blood pressure
• Blood pressure may remain normal, and a critically ill child may still
have signs of shock. However, it is likely that there will be a narrowed
pulse pressure.

9. Progession of shock
The progression of shock is unpredictable in the pediatric population, and
observing for changes in signs and symptoms can help detect shock
progression.

11. Treatment of shock

13. General actions
• Improve cardiac output
—Fluid resuscitation
—Vasopressors
• Improve the level of oxygen in the blood
—FiO2 100%
—Blood transfusion
• Decrease the body’s oxygen demand
—Fever
—Pain, anxiety
• Normalize metabolic and electrolyte imbalances
—Metabolic acidosis
—Hypoglycemia
—Hypocalcemia
—Hyperkalemia

14. Laboratory Values for Evaluation of Shock
• Lactate (Lactic Acid)
• Normal arterial lactate levels are < 2 mmol/L
• Complete Blood Count (CBC)
• Hb: indicator of blood and/or fluid loss, help determine fluid resuscitation effects and
blood transfusion
• WBC
• PLT: indicator of decreased PLT production and DIC
• Arterial Blood Gas
• Potassium
• Ionized Calcium
• Central venous oxygen saturation (ScvO2)
• Glucose

15. Types of shock

16. Hypovolemic shock

17. Signs & Symptoms of Pediatric Hypovolemic
Shock
• A: Typically the Airway of the child with hypovolemic shock will not be
significantly affected.
• B: The patient may experience some Breathing changes and this may be
recognized by a nonlabored tachypenea.
• C: The most notable changes will likely be seen with circulation. These
circulation changes include tachycardia, narrowing pulse pressure, possible
systolic hypotension, capillary refill time > 2 seconds, cool/pale skin, weak
to absent peripheral pulses, reduced urine output.
• D: Disability or neurological changes include decreased level of
consciousness.
• E: Exposing the patient to observe the child’s skin and extremities will often
reveal cool, pale, and mottled extremities.

18. Treatment of Pediatric Hypovolemic Shock
• The main treatment for the critically ill child with hypovolemic
shock is fluid resuscitation

19. Distributive shock
• Septic Shock
• Anaphylactic Shock
• Neurogenic Shock

20. Septic Shock Overview
• Warm Shock
• Cold Shock

21. Recognition of Septic Shock
• Airway:
• Breathing:
• increased respiratory rate (compensation for metabolic acidosis)
• There may be an increased work of breathing if the patient is developing ARDS
• Circulatory:
• Tachycardia (earliest sign)
• bounding peripheral pulses (warm shock)
• flash capillary refill (warm shock)
• widening pulse pressure (warm shock)
• capillary refill > two seconds (cold shock)
• mottled cool extremities (cold shock)
• Decreased urine output (caused by poor circulatory perfusion) (less than 1 ml/kg/hr is oliguria)
• narrowing pulse pressure (cold shock)
• Disability:
• Mental status changes occur as shock progresses.
• Restlessness → agitation → anxiousness → decreased mental status (warm and cold shock)
• Exposure:
• Petechial rash (result of meningococcemia or DIC)
• Hyperthermia (warm shock)
• Warm flushed skin (warm shock)
• Hypothermia (cold shock)
• Cool mottled extremities (cold shock)

22. Vasoactive drugs
• Fluid-Refractory “normotensive” shock
• When a child has fluid-refractory shock and presents with signs of poor perfusion but
has a normal blood pressure, vasoactive medications should be used to increase
myocardial contractility: dopa, adre
• Fluid-Refractory “warm” shock
• Signs of poor perfusion and hypotension (bounding pulses, flushed skin, and flash-
capillary refill)
• The vasoactive medication of choice for fluid refractory “warm” shock is
norepinephrine. The infusion rate should be between 0.1-2 mcg/kg/min. This should
be titrated to desired effect
• Fluid-Refractory “cold” shock
• Signs of poor perfusion and hypotension with vasoconstriction (mottled skin, delayed
capillary refill)
• vasoactive medications should be used to improve blood pressure by increasing
myocardial contractility with minimal vasoconstriction: EPINEPHRINE

23. Anaphylactic Shock: Management
• IM epinephrine
• concentration of 1:1,000
• 0.01 mg/kg
• Intramuscular
• Max dose 0.5 mg.
• May be repeated every 5‐15 min as needed if symptoms persist.

24. Neurogenic Shock Overview
• Neurogenic Shock is a type of distributive shock in which severe
central nervous system trauma (i.e. spinal cord injury) causes a rapid
loss in sympathetic stimulation
• This loss of sympathetic tone results in massive vasodilation and a
decrease in peripheral vascular resistance causing blood to pool in
the venous system.
• Signs & Symptoms: Children with neurogenic shock usually present
with hypotension and bradycardia because of the loss of sympathetic
tone. The following are signs and symptoms of neurogenic shock:

25. Cardiogenic shock
• Cardiogenic shock can also occur secondary to other forms of
untreated shock as a result of inadequate oxygen delivery to the
myocardium.

26. Signs of cardiogenic shock
• The 4 common clinical signs that distinguish cardiogenic shock
are tachycardia, dyspnea, jugular vein distention, and
hepatomegaly.
• Increased respiratory effort is often the distinguishing characteristic
that sets cardiogenic shock apart from other forms of shock.

27. Management of cardiogenic shock
• Improve cardiac function
• Myocardial Oxygen Demand
• Last Resort: ECMO

28. Obstructive shock
• Obstructive shock occurs when adequate oxygen and nutrient
delivery to the organs and tissues of the body is compromised as a
direct result of an obstruction to flow into or out of the heart
• The most common causes of obstructive shock in children are tension
pneumothorax, pulmonary embolism, and cardiac tamponade.
There are also several congenital abnormalities that can cause
obstructive shock. Examples include critical aortic stenosis and
coarctation of the aorta.