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shock management in children presentation
- 1. MANAGEMENT OF SHOCK PRESENTER :DR. PRIYANKA GANANI MODERATOR: DR. TANZILA & DR. SUJITH (PEDIATRIC INTENSIVIST)
- 2. What is shock??? ā¢ Shock is characterized by inadequate oxygen delivery to meet metabolic demands ā¢ Oxygen delivery (DO2 ) is less than Oxygen Consumption (< VO2)
- 4. ā¢ Oxygen delivery= Cardiac Output x Arterial Oxygen Content (DO2 = CO x CaO2) ā¢ Cardiac Output = Heart Rate x Stroke Volume ā¢ (CO = HR x SV) ā¢ SV determined by preload, afterload and contractility
- 5. What is neededto maintain Perfusion?? ā¢ PUMP-Heart ā¢ PIPES - Vessels ā¢ FLUID- Blood How can Perfusion fail?? ā¢ Pump Failure ā¢ Pipe Failure ā¢ Loss of Volume
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- 8. SIGNS OF SHOCK EarlySigns ā¢ Tachycardia ā¢ Normal blood pressure ā¢ Mildly delayed capillary refill ā¢ Fussy child Late Signs ā¢ Persisting tachycardia or bradycardia ā¢ Hypotension- LATE sign!! ā¢ Poor capillary refill ā¢ Altered mental status ā¢ Irregular breathing pattern ā¢ Poor muscle tone ā¢ Lower limit of SBP=70 + (2 x age in years)
- 9. Types of Shock ļObstructive ļ Pneumothorax ļ Cardiac Tamponade ļ Aortic Dissection ļ Cardiogenic ļ Myocardial dysfunction ļ Dysrrhythmia ļ Congenital heart disease ļ Dissociative ļ Heat, Carbon monoxide, Cyanide ļ Endocrine ļ Distributive ļ Anaphylactic ļ Neurogenic ļ Septic ļ Hypovolemic ļ Hemorrhage ļ Fluid loss ļ Drugs
- 10. Sign and symptomof shock History of trauma YES NO Hemorrhagic shock Obstructive shock Cardiogenic shock Neurogenic shock History of fluid loss
- 11. Yes No Hypovolemic shock Fever Hypothermia Immunocompromised Septicshock Yes No Abnormal cardiac output H/O FLUID LOSS
- 12. Abnormal Cardiac output CardiogenicShock Yes No Exposure to allergen Wheeze Urticaria If yes āAnaphylaxis shock If not then other causes like pulmonary emboli , adrenal insufficiency
- 13. Type of Shock Preload (PCWP) Cardiac Output Afterload (SVR) Tissue Perfusion Hypovolemic ļļ ļ ļ ļ Distributive ļ Or = ļ Or = ļ ļ ļ Cardiogenic ļ ļ ļ* ļ ļ ļ Obstructive ļ ļ ļ ļ ļ
- 14. Shock Management Principles 1.Supportive Care ā ABC of Life ā Intubation, mechanical ventilation, Oxygen as needed 2. Fluid Management 3. Treatment of underlying causes Regardless of the cause: Measure Glucose
- 15. Contā¦. ā¢ Airway ā Ifnot protected or unable to be maintained, intubate. ā¢ Breathing ā Always give 100% oxygen to start ā Saturation monitor ā¢ Circulation ā Establish IV access rapidly ā CFT and frequent BP monitor
- 16. Management-General ļGoal: increase oxygendelivery and decrease oxygen demand: ļ For all children: ā Oxygen ā Fluid ā Temperature control ā Correct metabolic abnormalities ļ Depending on suspected cause: ā Antibiotics ā Inotropes ā Mechanical Ventilation
- 17. Laboratory studies: ā ABG āBlood sugar ā Electrolytes ā CBC ā PT/PTT ā Blood grouping and cross matching ā Cultures
- 18. key steps tomanage shock 1. Give oxygen (for infants 0.5 -1 l/min, older children 1- 2 l/min). 2. Give 10% Glucose 2 ml/kg by IV if hypoglycemia present. 3.Keep the child warm. 4.Take blood samples for emergency laboratory tests 5. Give IV fluids 6. First assess the child for severe malnutrition before selecting treatment.
- 19. Intravenous Fluids A. ShockWith NO SAM ā¢ Rapid fluid boluses of 20 mL/kg (isotonic crystalloid can be administered by push or rapid infusion device (pressure bag) ā¢ signs of fluid overload (i.e., the development of increased work of breathing, rales, cardiac gallop rhythm, or hepatomegaly) should be watched. ā¢ In the absence of these clinical findings, children can require 40ā60mL/kg in the first hour or more depending upon the type of shock.
- 20. ā¢ Acc toFEAST ( Fluid Expansion as Supportive Therapy) trail which shows increase mortality in children with who receive fluid bolus as compared to maintaince fluids particularly in anemia and malnourished children. ā¢ This study inferred that rapid fluid resuscitation may not be the best therapeutic strategy for all children, especially in resource-limited settings where facilities to provide advanced ventilation and hemodynamic support are inadequate
- 21. Consider Blood Transfusionif HB <10 gm/dl. If shock remains refractory following 60-80 mL/kg of volume resuscitation, vasopressor therapy (norepinephrine, or epinephrine) .
- 22. Shock With SAM(operationalguidelines MOHFW 2011) ā¢ IV Fluid (15ml/kg over 1hr). ā¢ Give normal saline or Ringer lactate with 5% glucose. ā¢ check PR and RR every 5-10 minutes. ā¢ If improved, change the IV fluid with oral intake/ Resomal after 2 hr. ā¢ If there is improvement: Repeat 15ml/kg over 1 hr
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- 25. ā¢ Supplemental oxygenand optimal airway positioning should be provided at presentation for all patients with shock, consistent with PALS guidelines ā¢ Children with persistent or worsening shock should be considered to be at high risk for deterioration and should receive ventillatory support.
- 26. ā¢ Patients withshock of any etiology are particularly vulnerable to the hemodynamic effects of sedatives and analgesics ā¢ Emphasizing the importance of prompt appropriate fluid resuscitation and inotrope infusion (peripheral or central) prior to airway instrumentation in spontaneously breathing patients.
- 27. ā¢ Ketamine remainsan important agent for intubation of pediatric patients with shock (dissociation while maintaining or augmenting SVR) ā¢ Atropine increases the HR and protects against the deleterious effects of bradycardia,). ā¢ Atropine does not cause cardiac dysrhythmias and is not contraindicated in children exhibiting tachycardia
- 28. ā¢ The useof ketamine with atropine pretreatment is considered to be the sedative/induction regimen which best pro- motes cardiovascular integrity
- 29. ā¢ The commonestshock which can be missed even on examination. Persistent tachycardia + blood gas showing metabolic acidosis +/- increase lactate SUSPECT WARM SHOCK
- 30. After fluid andelectrolyte management if no improvement 15 min: Fluid refractory Shock Begin with IV inotropes ,preferably Epinephrine 0.05- 0.3mcg/kg/min. If warm shock add norepinephrine 0.05ug/kg/min Use dopamine if above NA. Titrate accordingly 60 minutes
- 31. No improvement after60 minutes consider Catecholamine resistant shock If at risk of adrenal insufficency consider Hydrocortisone Use fluids, Inotropes, Vasopressor, Vasodilator GOAL : normal MAP ā CVP, ScvO2 >70% Normal BP Cold shock , on Epinephrine ? Start Milrinone If successful consider Levosimendon Low BP Cold shock ScvO2 <70% On Epinephrine? Add Norepinephrine for normal DBP Add dobutamine, Levosimendon Milrinone as required Low BP Warm Shock ScvO2 >70% on Norepinephrine ? If equivolemic add Vassopressin If no , add Epinephrine Dobutamine Levosimendon
- 32. Persistent Catecholamine -resistant Shock ? Refractory Shock? Evaluate pericardial effusion or pneumothorax ECMO American college of critical care medicine for time sensitive ,goal directed stepwise management (2017)
- 33. Antibiotics should beadministered within the first hour of recognition of septic shock Antibiotic choice must be broad spectrum, covering gram-positive, gram-negative, and anaerobic bacteria when the source is unknown
- 34. cardiogenic shock RX GOAL: ā¢ increase CO ā¢ Treat reversible causes ā¢ Decrease myocardial workload
- 35. Sign of cardiogenicshock Cardiac sign : murmur, gallop, decrease peripheral pulses Extra cardiac sign: tachypnea, crackle , hepatomegaly, hypotension Ventillation optimization Oxygenation , high flow mask Non invasive ventillation Invasive ventillation Transfuse blood to maintain Hb >10gm/dl Pre and Afterload optimization (use of fluid or loop diuretics as condition warrants)
- 36. 1.Treatment of curabledisease Pericardocentesis , pleural drain , 2. Treatment of rhythm disorder 3. Treatment of electrolyte imbalances Drug Therapy First line Dobutamine 5-15ug/kg/mi n Max 20 ug/kg/min Second Line 1.NorAd start at0.01ug/kg/min if SVR low 2.If persistent hypotension despite dobutamine replace it with milrinone āepinephrine. Third line Terlipresin/ vassopressin ECMO Expert recommendation for management of cardiogenic shock in children (Annals of intensive care 2016)
- 37. ANAPHYLACTIC SHOCK ā¢ Airway,withdrawl of Ag, fluid administration ā¢ epinephrine - 0.01ml/kg(1:1000 solution) IM ā¢ Diphenhydramine : 1.25 mg/kg IM/PO ā¢ Corticosteroids (methylprednisolone 1-2 mg/kg upto 125 mg IV) ā¢ Vasopressors or Inotropes
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- 39. management Fluid administration fortreating hypotension crystalloid (0.9% sodium chloride, ringerās lactate) or colloid (albumin, blood products) fluids and evaluated for any ongoing blood loss. signs of fluid overload must be seen before giving another bolus
- 40. Contā¦. ļ¼Vasopressors & Inotropes ļ¼Correcthypothermia ļ¼Treat bradycardia with atropine (0.01-0.03mg/kg/dose , max 1mg) IV ļ¼Observe and prevent DVT ļ¼May benefit from: phenylephrine or vasopressin to increase SVR
- 41. obstructive shock primary insultmust be immediately addressed. Such as... ā¢ pericardiocentesis for pericardial effusion ā¢ pleurocentesis for pneumothorax ā¢ thrombectomy/thrombolysis for PE. ā¢ prostaglandin infusion for ductus-dependent cardiac lesions.
- 42. Physiologic indicators andtarget goals After the initial fluid bolus, evaluate for: 1)Heart rate (as per PALS threshold) 2) Quality of central and peripheral pulses (strong, distal pulses equal to central pulses) 3) Skin perfusion (warm, with capillary refill <2 seconds) 4) Mental status (normal mental status) 5) Urine output (ā„1 mL/kg per hr) 6) BP (systolic pressure at least fifth percentile for age)
- 43. Complications of Shock 1.Shock Lung (ARDS) 2. Acute Renal Failure 3. Gastrointestinal Ulceration 4. Disseminated Intravascular Coagulation 5. Multisystem Organ Failure 6. Death
- 44. Take home message ā¢Emphasis on systemic based approach to eliminate undue delay in recognition and treatment of septic shock in ED. ā¢ Focus on individual physiology and the setting in which patient being treated. Optimal fluid therapy should be given according to resource availability ā¢ Epinephrine or norepinephrine should be used a first line of inotropes depending upon type of shock(rather than dopamine) ā¢ Timely initiation of inotropes along with titration should be done.
- 45. Refrences 1.American College ofCritical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock(2017) 2. Nelson textbook of pediatrics 21st edition 3. Expert recommendation for management of cardiogenic shock in children (Annals of intensive care 2016) 4. American Heart Association PALS guidelines 5. Advances in management of pediatric septic shock (IAP2018 )
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