PALS 2020 Shock

For septic shock, how soon should fluid resuscitation begin

10 to 15 minutes after recognized shock

Hypotension is calculated blood pressure of less than? Plus_____ times the age in years

70 mmHg 2 70mmHg+2xage in years

What is the most appropriate method of delivering a rapid fluid boluses?

A syringe and 3 way stopcock

Cardia output=Stroke volume X Heart Rate

According to this formula if the heart rate decreases, stroke volume must increase commensurately to maintain the cardiac output.

Adequate treatment after the first hour after the onset of what is important in septic shock?

After the onset of symptoms tis critical to maximize survival of a child in septic shock. Immediate 10 to 15 minutes

Identifying Shock Signs

Altered Mental status Altered HR Altered Temp Altered perfusion Hypotension

What signs distinguish anaphylactic shock?

Angioedema ( Swelling of the face, lips and tongue) Respiratory distress with stridor, wheezing or both Urticaria (Hives)

Adjunct treatments for anaphylactic shock

Antihistamines corticosteroids (methylprednisone)

As shock develops, compensatory mechanisms attempt to?

Attempt to maintain O2 delivery to vital organs

Fluid resuscitation with hemorrhagic shock begins?

Begins with rapid infusion of isotonic crystalloid in boluses of 20 ml/kg. 3 boluses of 20 ml/kg to replace 25% of lost blood

When O2 delivery to the tissues is compromised what happens?

Blood flow is redirected or shunted from nonvital organs and tissues ( like skin, skeletal muscles, gut, kidneys) to vital organs like brain, heart

Use what to determine shock severity?

Blood pressure

When SVR cannot increase further blood pressure?

Blood pressure begins to decline. Then O2 delivery to organs is severely compromised

systolic pressure

Blood pressure in the arteries during contraction of the ventricles.

For pts with cardiogenic shock boluses may be given how? Why is this important? This can compromise?

Bolus should be Small, given more frequently and slower with caution. Important bc rapid delivery of fluids in the setting of poor myocardial function can cause pulmonary edema and further impair cardiac output. this can compromise Oxygenation, ventilation, and cardiac output

How is anaphylactic shock characterized?

By Venodilation(dilation of blood vessels), vasodilation, increased capillary permeability and pulmonary vasoconstriction.

As cardiac output decreases blood pressure is maintained by?

By an increase in SVR

How can cardiac output increase?

By an increase in heart rate, in stroke volume or both

The physiology of hypovolemic shock is characterized by what?

By decreased preload leading to reduced stroke volume and low cardiac output

Adequate fluid resuscitation in hypovolemic shock is determined by?

By extent of volume depletion Type of volume loss (Blood, electrolyte fluid and protein fluid)

How can shock be characterized?

By inadequate peripheral and end organ perfusion. Also it can be characterized by low cardiac output and decreased level of consciousness.

How is shock severity frequently characterized?

By its effect on systolic blood pressure. Shock is described as compensated if compensatory mechanisms can maintain a systolic blood pressure within normal range, or above the fifth percentile systolic blood pressure for age

What else can support stroke volume?

Can be supported by increased venous smooth muscle tone, improving venous return to the heart and preload

All types of shock can do what to organs?

Can result in impared function of vital organs such as the brain (Decreased level of consciousness) and kidneys ( Low urine output and ineffective filtering)

Hypovolemic shock is the most common?

Common type of shock in pediatric pts because its caused by extravascular fluid loss such as diarrhea, dehydration, inadequate fluid intake, osmotic diuresis (DKA), third space losses, large burns. As well as intravascular such as hemorrhage

Obstructive shock

Conditions that physically impair blood flow by limiting venous return to the heard or limit the pumping of blood from the heart, resulting in decreased cardiac output

Common causes of cardiogenic shock?

Congenital heart disease Myocarditis cardiomyopathy Arrhythmias Poisoning or drug toxicity Myocardial injury ( Trauma)

If signs of shock do not persist

Consider critical care consultation Initiate and titrate epinephrine or norepinephrine

What are the major functions of the cardiopulmonary system?

Delivers oxygen to body tissues Removes metabolic by products of cellular metabolism

What does cardiac output determine and vascular resistance determine?

Determines adequate blood flow to the tissues

Within the first hour of septic shock what should be done?

Draw labs Administer antibiotics within 1 hour after first medical contact Assess carefully after each fluid bolus. Stop fluid if rales, respiratory distress or hepaomegaly develops Give antipyretics (chiefly of a drug) used to prevent or reduce fever) is needed

Anaphylactic shock treatments?

Epi is first line. IM epinephrine or by autoinjector. Second dose after 10-15 minutes in severe anaphylaxis. Frequent, low dose infusion (less than 0.05 mcg/kg per minute is effective Isotonic crystalloid fluid boluses as needed Albuterol for bronchospasm

What is the most appropriate vasoactive drug to use in fluid refractory septic shock?

Epinephrine or norepinephrine

Critical care therapies for septic shock

Establish central venous and intra-arterial pressure monitoring Continue epi/norepinephrine and bolus fluid therapy as needed to treat shock Verify Adequate airway, oxygenation and ventilation Consider stress dose of hydrocortisone if hemodynamic remain inadequate despite fluid resuscitation and vasoactive drug therapy

Initial management of distributive shock focuses on? Use what kind of agents?

Expanding intravascular volume, to correct hypovolemia ,and fill the expanded dilated vascular space. Use vasoactive agents if the child remains hypotensive or poorly perfused despite rapid bolus fluid administration or if low diastolic pressure

What are initial assessments for finding septic shock?

Fever normal elevated, or decreased wbc Hypothermia

If child does not improve after three boluses (60 mL/kg) indicates?

Fluid loss is underestimated Type of Fluid replacement may need to be changed Ongoing fluid loss (Occult bleeding or bleeding that is not visible) Initial assumption of etiology of shock may be wrong

Acute treatments of shock focuses on?

Focuses on restoring O2 delivery to the tissues and improving balance between tissue perfusion and metabolic demand

What are the limits of increased cardia output produced by increasing heart rate?

If the rate is too fast, as can happen with tachyarrhythmias, stroke volume can fall bc there is inadequate time to fill the heart.

How do children with hypovolemic shock have the best chance of survival?

If they receive appropriate volume of fluid within the first hour after resuscitation.

Goals in treating shock?

Improve O2 delivery Balance tissue perfusion and metabolic demand Support organ function Prevent progression to cardiac arrest

With cardiogenic shock most pts will need what kind of support?

Inotropic support with medications such as milrinone or epinephrine.

Tachypnea

Is a respiratory compensation to maintain acid base balance, is often present in hypovolemic shock

If cardiac output is inadequate, tissue perfusion is? Signs of poor tissue perfusion?

Is compromised, even if blood pressure is normal. Lactic acidosis and end organ dysfunction will be present even if blood pressure is normal

What is another mechanism to maintain stroke volume and cardiac output?

Is increased strength of cardiac contractions, or contractility, with more complete emptying of the ventricles

The clinical presentation of distributive shock is?

Is more variable that that of hypovolemic shock.

Shock may be present even if the childs bp is?

Is normal

Distributive shock is? What is it associated with?

Is present in inadequate blood flow to some tissue beds but too much blood flow to others. It is associated with vasodilation, capillary leak and decreased heart function

The body's first action to maintain cardiac output is to?

Is to increase heart rate, or tachycardia, which can increase cardiac output to a limited degree

What is the preferred initial fluid shock resuscitation?

Isotonic crystalloids

Rapid administration of what is the primary therapy of hypovolemic shock? In what time frame?

Isotonic crystalloids. Rapidly infuse 20mL/kg fluid boluses Administer isotonic crystalloid bolus of 20 mL/Kg in over 5 to 20 min.

Most typical sign of distributive shock?

Like hypovolemic shock most children have tachycardia. Other signs are poor perfusion, cool skin with delayed capillary refill.

What characterized cardiogenic shock?

Marked tachycardia, high SVR and decreased cardiac output

Unlike pts with hypovolemic shock most children in distributive shock may have?

May have warm flushed skin with brisk capillary refill

When you dont know a childs weight how can you quicky determine it?

Measure using a color coded length based tape

Myocardium

Muscular tissue of the heart

Observation is indicate for identification and treatment of?

Of late phase treatment. Late phase symptoms may occur in 25%-30% of children several hours after acute phase symptoms.

Treatment of shock

Optimizing O2 content of the blood Improving volume and distribution of cardiac output Reducing O2 demand Correcting metabolic derangements

What will occur if adequate o2 delivery to the tissues is not maintained?

Organ dysfunction

If the child remains hemodynamically unstable despite 2 to 3 boluses of 20 ml/kg of isotonic crystalloid what do you do?

Packed red blood cells should be administered. Must also give platelets and fresh frozen plasma to prevent coagulation (blood turning solid)

Causes of obstructive shock

Pericardial tamponade Tension pneumothorax Ductual-dependent congenital heart defects Massive pulmonary embolism

Why are the early signs of septic shock difficult to recognize?

Peripheral perfusion may initially appear adequate

How to asses a childs response to each fluid bolus?

Physical examination vital signs, and urinary output

Components of general shock management?

Position the child Optimize arterial oxygen content(give O2) SUpport ventilation Establish vascular access Begin fluid resuscitation Monitor Perform frequent reassessment

What are some adverse reactions that indicate you should stop rapid fluid bolus administration?

Rales Respiratory distress Hepatomegaly

Hypovolemic shock

Refers to a clinical state of reduced intravascular volume (blood volume) and extravascular fluid

Anaphylactic shock

Results from a severe allergic reaction. Can develop extremely fast often within minutes

Septic shock? Signs and symptoms?

Results from a systemic infection. Severe infections can release toxins that cause small blood vessels to dilate and leak fluid into tissues Infection, fever, petechial or purpuric rash, low wbc, hypothermia. takes hours to progress

Cardiogenic shock

Results from inadequate tissue perfusion caused by poor myocardial infarction

Components of management of septic shock are?

SUpport adequate airway, breathing, and circulation Monitor heard rate, bp, and pulse ox Establish IV/IO accsee Give Boluses of 10 to 20 mL/kg (10 mL/kg for neonates and those with preexisting heart disease) isotonic crystalloid

Most common type of distributive shock?

Septic shock Secondary is Anaphylactic shock

Shock

Shock is defined as a physiologic state characterized by inadequate tissue perfusion to meet metabolic demand and tissue oxygenation.

What types of shock can cause a high cardiac output?

Shock thats caused by sepsis or anaphylaxis cardiac out put can be high

Hypotensive shock

Shock with a low bp. occurs when compensatory mechanisms have failed

Compensated shock

Shock with adequate blood pressure. May have a normal or high systolic bp due to fight or flight response

What are the typical clinical findings with compensated shock

Tachycardia Delayed capillary refill Decreased urine output

Name the compensatory mechanisms

Tachycardia Increased systemic vascular resistance (SVR) (vasoconstriction) Increased strength of cardiac contraction (Contractility) Increase in venous smooth muscle tone

Clinical findings of compensated shock

Tachycardia, delayed capillary refill, and decreased urine output

Name the compensatory mechanisms of hypovolemic shock

Tachycardia, increased SVR, and increased cardiac contractility are the main mechanisms

What is a clinical finding of hypovolemic shock?

Tachypnea

What should be evaluated with septic shock before severe organ dysfunction develops?

Temperature HR Systemic perfusion BP Clinical signs of end organ function

pulse pressure

The difference between the systolic and diastolic blood pressure often narrows bc increased SVR raises the diastolic pressure.

The more time that passes between the onset of signs of shock and the restoration of adequate O2 delivery and organ perfusion, what happens to the child?

The poorer the outcome. Immediate intervention for a child in shock may be lifesaving

Cardiac output

The volume of blood pumped by the heart per minute is the product of stroke volume and heart rate Cardia output=Stroke volume X Heart Rate

Stroke volume

The volume of blood pumped by the ventricles with each contraction

Tissue hypoxia

This is present when a region of the body or an organ is deprived of adequate O2 supply.

Whats key to preventing deterioration from compensated hypovolemic shock to hypotensive and refractory shock?

Timely administration of fluid it key

norepinephrine

Together with adrenaline, norepinephrine increases heart rate and blood pumping from the heart. It also increases blood pressure and helps break down fat and increase blood sugar levels to provide more energy to the body

When SVR cannot increase O2 delivery to myocardium becomes? This can cause?

Ultimately O2 delivery to the myocardium becomes inadequate, causing myocardial dysfunction, decreased stroke volume and hypotension Can rapidly lead to cardiovascular collapse, cardiac arrest, and irreversible end organ injury

When will you see signs of poor tissue perfusion?

When cardiac output is decreased and blood pressure is normal

Hypotensive shock

When compensatory mechanisms fail and systolic bp declines shock is classified as hypotensive, previously referred to as decompensated

If cardiac output is compromised, signs or poor perfusion will be?

Will be Absent even if blood pressure is normal

How can you identify hypotensive shock and compensated shock?

You can easily identify hypotensive shock by measuring blood pressure, while you may find it more difficult to diagnose compensated shock.

What is another way of terming hypotensive shock?

compensated shock obstructive shock anaphylactic shock

Cardiogenic bolus doses? Time to give bolus? What do you monitor?

give 5 to 10 mL/kg of body weight using isotonic crystalloid. Give over 10 to 20 minutes Carefully monitor hemodynamic and respiratory parameters.

Hemorrhagic shock

occurs when the body begins to shut down due to large amounts of blood loss.

diastolic pressure

occurs when the ventricles are relaxed; the lowest pressure against the walls of an artery

How is blood pressure determined

product of Cardiac output and Systemic Vascular Resistance (SVR)

vasoconstriction

the constriction of blood vessels, which increases blood pressure.

metabolic demand

what cardiac output is normally equal to