k13 - Shock Ped
-
Upload
yolanda-simamora -
Category
Documents
-
view
248 -
download
3
description
Transcript of k13 - Shock Ped
![Page 1: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/1.jpg)
Shock in pediatric
EM1-K13
![Page 2: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/2.jpg)
Shock
A state of circulatory dysfunction that fails to provide sufficient oxygen and nutritions to meet the metabolic needs of vital organs and peripheral tissues
![Page 3: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/3.jpg)
Oxygen Delivery
DO2 = CaO2 x COCaO2 = (Hgb x 1.34 x SaO2) + (0.003 x PaO2)CO = HR x SV
![Page 4: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/4.jpg)
Decreased DO2 - GlucoseDecreased ATP production
Loss of membrane integrity
K efflux, Na influx
Ca influx
Formation of damaging free radicals
Increases Nitric Oxide production
Activates proteases
Damages mitochondria
Damage cellular contents
Elaborated inflammatory mediators (eg, IL-1B, Tumor Necrosis Factor-α)
Microvascular thrombosis and loss of vascular integrity
Further edema formation
Cell death
Cellular edema
Pathophysiology of hypoxic-ischemic injury
Multiple system organ failure
Death
Disturbance cellular homeostasis
![Page 5: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/5.jpg)
TachycardiaCool extremitiesProlonged capillary refillWeak peripheral pulsesNormal blood pressure
Depressed mental statusDecreased urine outputMetabolic acidosisTachypneaWeak central pulses
©Compensated
©Inadequate end organ perfusion
©Decompensated
Sign of shock state & progress
Hypotension
![Page 6: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/6.jpg)
Major categories of shock
Hypovolemic
The most common type; circulating intravascular blood volume decrease; decrease in preload; decrease CO
Cardiogenic
Heart rate abnormalities (heart block, ventricular, supraventricular tachycardia), decreased myocardial contractility
Distributive
Relative uncommon; maldistribution of tissue blood flow due to decreased systemic vascular resistance,
ObstructiveExtrinsic force acting on intrathoracic structures (great vessels, ventricle)
![Page 7: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/7.jpg)
Etiology and typical presentation of
Hypovolemic ShockEtiology Diarrhea
Blood loss (traumatic)
Presentation
Tachycardia Narrowed pulse
pressure Delayed capillary refill Cool extremities Late stages:
hypotension
![Page 8: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/8.jpg)
Etiology and typical presentation of
Cardiogenic ShockEtiology CHD, cardiomyopathies, myocarditis, coronary infark
Dysrhytmia Acidosis, hypoxic-ischemic,
poisoning, metabolic disorders Prolonged shock Sepsis
Presentation
Bradycardia/tachycardia Gallop Barely perceptible pulses Cardiomegaly Rales
![Page 9: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/9.jpg)
Etiology and typical presentation of
Distributive ShockEtiology Early septic Shock
Anaphylaxis Toxic ingestion Spinal/ epidural anesthesia Head/spinal cord injuries
Presentation Flush appearance Warm extremities Bounding pulses Tachycardia Wide pulse pressure Capillary refill may be
instantaneous
![Page 10: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/10.jpg)
Etiology and typical presentation of
Obstructive ShockEtiology · CHD (Aortic stenosis/
coarctation)· Tension pneumothorax· Hemopneumothorax· Pericardial effusion
Presentation
· Tachycardia· Cool extremities· Delayed capillary refill· Narrow pulse pressure· Distended neck veins, distant
heart tones, asymmetric breath sounds
![Page 11: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/11.jpg)
Evaluation of shock
· Assesment of Airway, breathing and circulation
· Blood glucose· History and physical examination
![Page 12: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/12.jpg)
Assesment of airway, breathing and circulation
Airway · Airway patencyBreathing · Respiratory rate
· Respiratory pattern· Work of breathing (respiratory
distress)· Continuous pulse oxymetry
Circulation · Bradycardia· Tachycardia· Rhythm abnormalities· Central and distal pulse· Capillary refill (normal : complete
between 2 to 3 seconds)· Hypotension (late finding)
![Page 13: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/13.jpg)
Normal respiratory rates in children
Age Respiratory rate (breaths/minute)
Newborn-1 year
30-60
1-3 years 25-403-12 years 20-30>12 years 12-20
![Page 14: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/14.jpg)
![Page 15: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/15.jpg)
Normal heart rates in children
Age Heart rate (beats/minute)
Newborn 80-200< 2 years 80-1802-10 years 60-150>10 years 60-100
![Page 16: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/16.jpg)
Neonatal blood pressurebased on birth weight
![Page 17: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/17.jpg)
Lower limit of systolic blood pressure by age
Age Systolic blood pressure (mm Hg)
Newborn 60< 1 years 701-10 years 70 + (age in years x 2) > 10 years 90
![Page 18: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/18.jpg)
Blood glucose
· Bedside assessment· Infant are vulnerable to hypoglycemia· Hypoglycemia may result
severe/permanent neurologic disability
![Page 19: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/19.jpg)
History and Physical Examination
· History· Serial assessment of vital signs, mentation,
and perfusion· Fever (serious infection?), hypothermia
(sepsis?)· The lung fields auscultation (rales :
hypervolemia?)· Gallop rhythm (underlying heart disease,
hypervolemia)· Palpation of liver edge below the costal
margin (hypervolemia, cardiac failure?)· Purpuric or petechial rashes (infectious?)· Secondary survey (injuries?)
![Page 20: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/20.jpg)
1. ABC’s of life support2. Vascular access3. Fluid resuscitation 4. Inotropic-Vasoactive5. Control acidosis6. Monitoring, laboratory studies,
CXR7. Treat the underlying cause
Management of shock
![Page 21: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/21.jpg)
ABC’s of life support
· Open airway· Suction· High Concentration O2· Assist ventilation (as needed)· Control bleeding· Shock position· Keep warm
![Page 22: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/22.jpg)
![Page 23: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/23.jpg)
![Page 24: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/24.jpg)
· Use isotonic crystalloid solution (eg, lactated Ringer’s solution or normal saline) or 5 % albumine.
· Fluid boluses, 20 mL per kg, severe : 40-60 ml/kg, max 200 ml/kg rapidly until the shock is resolved (delivered in 5-10 minutes)
· Observing for signs of fluid overload (increased work of breathing, rales, gallop rhythm, or hepatomegaly)
· Use a glucose-containing solution to only treat documented hypoglycemia
· Correct hypocalcemia· Insufficient data to recommendation or
against using hypertonic saline for shock associated with head injuries or hypovolemia
Fluid resuscitation
![Page 25: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/25.jpg)
Inotropes-Vasoactive agents is use if shock requiring pharmacologic improvement of cardiac contractility function or decompensated shock refractory to volume expansion alone
Inotropes-Vasoactive
![Page 26: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/26.jpg)
Inotropes/Vasoactive AgentsDopamine 1-5 mcg/kg/min: dopaminergic; 5-15
mcg/kg/ min: more beta-1; 10-20 mcg/kg/min: more alpha-1
Dobutamine 2.5-15 mcg/kg/min; mostly beta-1, some beta-2
Epinephrine 0.05-0.1 mcg/kg/ min: mostly beta-1, some beta-2; >0.1 to 0.2 mcg/ kg/min: alpha-1
Nor-epinephrine 0.05-0.2mcg/kg/ min; Use up to 1mcg/kg/min; only alpha and beta-1
Milrinone 50mcg/kg load then 0.375-0.75 mcg/kg/min; Phosphodiesterase inhibitor; results in increased inotropy and peripheral vasodilation (greater effect on pulmonary vasculature)
![Page 27: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/27.jpg)
Control acidosis
· Metabolic acidosis may become evident as child’s condition worsen
· Na Bic no longer routinely recommended because the use of Na Bic may increase intracellular acidosis
· Fluid resuscitation, vasoactive infusion and adequate ventilation/oxygenation are the main management
· Tromethamine /THAM given slowly (3-5 ml/kg) may use in extreme condition (i.e. pH < 7)
![Page 28: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/28.jpg)
Monitoring, lab studies, and CXR
· Monitoring HR, BP continuously· Clinical evaluations/5 min until the patient is
stable· Urine output monitoring with an indwelling
catheter· Lab : ABG, serum electrolytes, glucose, Ca
levels, CBC, PT/PTT, blood type/cross match, and culture
· Evaluate ET tube position, heart size, and pulmonary status by CXR
![Page 29: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/29.jpg)
Treat the underlying cause
· Trauma: ongoing bleeding may need to be addressed surgically
· Myocardial failure: inotropic medications· Sepsis: isolated and treat the infectious
organism with appropriate AB’s
![Page 30: k13 - Shock Ped](https://reader036.fdocuments.net/reader036/viewer/2022062300/563dbafa550346aa9aa93dee/html5/thumbnails/30.jpg)