pediatric Shock management seminar ppt slide

this slide is about pediatric shock and management
since shock is emergency case it is good to know about it and treat it accordingly

1. MANAGEMENT OF PEDIATRIC SHOCK

2. INTRODUCTION EPIDEMIOLOGY TYPES OF SHOCK PATHOPHYSIOLOGY APPROACH TO A PATIENT WITH SCHOCK MANAGEMENT OF PEDIATRIC SHOCK PROGNOSIS OUTLINE Shock

3. Define shock? Types of shock? Shock

4. Introduction Shock is an acute process characterized by the body's inability to deliver adequate oxygen to meet the metabolic demands of vital organs and tissues. So, insufficient oxygen at a tissue level is unable to support a normal aerobic cellular metabolism, resulting in a shift to less efficient anaerobic metabolism. Shock

5. 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. Mortality is mostly due to associated complication and MODS Shock

6. Types of Shock Hypovolemic Cardiogenic Distributive Obstructive, and Septic Shock

7. Hypovolemic shock The most common cause of shock in children worldwide, Hypovolemic shock is due to loss of blood volume, causes decreased preload, stroke volume, and CO . It is most frequently caused by diarrhea, vomiting, or hemorrhage. Shock

8. Cardiogenic shock I s seen in patients with congenital heart disease (before or after surgery, including heart transplantation) or those with congenital or acquired cardiomyopathies, including acute myocarditis. Is a problem due to the heart not being able to generate certain amount of power to pump blood to the tissue . Shock

9. Obstructive shock S tems from any lesion that creates a mechanical barrier that impedes adequate cardiac output, which includes - P ericardial tamponade - T ension pneumothorax - P ulmonary embolism - D uctus-dependent congenital heart lesions Shock

10. Distributive shock Is caused by inadequate vasomotor tone, which leads to capillary leak and misdistribution of fluid into the interstitium. Includes - Anaphylactic, - N eurogenic, - S eptic shock Shock

11. Cont... A naphylactic shock : is due to severe systemic allergic reaction s uch as food, drug allergens, bee stings, insect bites Neurogenic shock-loss of sympathetic vascular tone secondary to acute spinal cord or brainstem injury or regional anesthesia - S o there will be unopposed vagal tone(leads to bradycardia,vasodilation) Shock

12. Septic shock I s often discussed synonymously with distributive shock, but the septic process usually involves a more complex interaction of distributive, hypovolemic, and cardiogenic shock. Shock

13. Pathophysiology Extracorporeal Fluid Loss Hypovolemic shock may be a result of direct blood loss through hemorrhage or abnormal loss of body fluids (diarrhea, vomiting,burns, diabetes mellitus or insipidus, nephrosis). Lowering Plasma Oncotic Forces Hypovolemic shock may also result from hypoproteinemia (liver injury, or as a progressive complication of increased capillary permeability). Abnormal Vasodilation Distributive shock (neurogenic, anaphylaxis, or septic shock) occurs when there is loss of vascular tone—venous, arterial, or both (sympathetic blockade, local substances affecting permeability, acidosis, drug effects, spinal cord transection). Shock

14. Increased Vascular Permeability Sepsis may change the capillary permeability in the absence of any change in capillary hydrostatic pressure (endotoxins from sepsis, excess histamine release in anaphylaxis). Cardiac Dysfunction Peripheral hypoperfusion may result from any condition that affects the heart’s ability to pump blood efficiently Shock

15. COMPENSATORY MECHANISMS

16. Phases Compensated Occurs earlier in the process BP is maintained HR is elevated Decompensated Occurs late in the process BP is low, hypotension Organ damage starts to be seen Irreversible MOD has developed Shock

17. Systemic Inflammatory Response Syndrome (SIRS) Two of 4 criteria, 1 of which must be abnormal temperature or abnormal leukocyte count: 1. Core temperature >38.5°C (101.3°F) or <36°C (96.8°F) (rectal, bladder, oral, or central catheter) 2. Tachycardia: Mean heart rate >2 SD above normal for age or Unexplained persistent elevation over 0.5-4 hr or In children <1 yr old, persistent bradycardia over 0.5 hr (mean heart rate <10th percentile for age ) Shock

18. Cont... 3. Respiratory rate >2 SD above normal for age 4. Leukocyte count elevated or depressed for age or >10% immature neutrophils Shock

19. Other sepsis-scoring criteria The sequential organ failure assessment (SOFA) score and the abbreviated version (qSOFA) are a newer set of criteria. SOFA and qSOFA help predict mortality associated with sepsis. Can be used as an alternative to SIRS Sepsis is suspected when 2 of the qSOFA criteria are met. The 3 criteria for the qSOFA score include: RR -tachypneic Systolic blood pressure -hypotension Altered mental status Shock

20. Severe Sepsis Sepsis plus 1 of the following: 1. Cardiovascular organ dysfunction, defined as: Despite >40 mL/kg of isotonic intravenous fluid in 1 hr: Hypotension <5th percentile for age , systolic blood pressure <2SD below normal for age or Need for vasoactive drug to maintain blood pressure OR Two of the following: Unexplained metabolic acidosis: base deficit >5 mEq/L , Increased arterial lactate: >2 times upper limit of norma l, Oliguria: urine output <0.5 mL/kg/hr , Prolonged capillary refill: >5 sec or Core-to-peripheral temperature gap: >3°C (5.4°F) Shock

21. Cont... 2. (ARDS), bilateral infiltrates on chest radiograph, and no evidence of left-sided heart failure. or Sepsis plus ≥2 organ dysfunctions (respiratory, renal, neurologic, hematologic, or hepatic). Shock

22. Approach to a child with shock Directed history GI loss Kidney loss Bleeding Burn Decreased urine out put Past medical history heart disease Surgical hx steroid use medical problems Shock

23. Physical examination The clinical presentation of patient with shock varies according to the type of shock and the phase of shock General Appearance Active bleeding site, acute burn Change in level of consciousness Cardiorespiratory distress Well nourished or malnourished Shock

24. Cont... Vital sign PR- tachycardia RR- usually tachypnea BP- norm a l or decreased. The classification of shock may be suggested by changes in the pulse pressure. Narrow PP(<30 mm Hg) Hypovolemic and cardiogenic shock Wide (>40 mm Hg) distributive shock Temperature- febrile or hypothermia indicating septic shock Shock

25. Cont... Respiratory system Signs respiratory distress stridor or wheezing indicating anaphylaxis Cardiovascular system Pulse distended neck vein-suggesting heart failure abnormal heart sound- murmur, gallop, Shock

26. Gastrointestinal system hepatomegaly abnormal abdominal findings like abdominal distension, tenderness, is consistent with bowel obstruction, perforation, or peritonitis, septic shock Musculoskeletal system Edema Integumentary system Cool extremities, warm extremities Prolonged capillary refill Nervous system Level of consciousness-alert or lethargic Muscle tone-hypotonia Shock

27. APPROACH TO A PATIENT Fever Tachycardia O rthostatic hypotension Blood pressure –hypotension , unless compensated shock Respiratory rate- tachypneic Altered mental status Delayed capillary refill , decreased peripheral pulses Prolonged capillary refill: >3 sec except in case of warm shock Shock

28. Dry mucous membranes, dry axillae, poor skin turgor, and decreased urine output. - o liguria: urine output <0.5 mL/kg/ hr Distal Cool extremities Petechiae , diffuse erythema, ecchymoses , ecthyma gangrenosum , and peripheral gangrene . Shock Cont...

29. Cont... Early signs(compensated) Increased heart rate Poor systemic perfusion Late signs(decompensated/hypotensive) Hypotension week central pulses Altered mental status Shock

30. Cont... Septic Shock is unique in that hypotension and poor organ perfusion may be present despite “good” perfusion ans is still a sign of decompensating. For this reason we may get fast capillary refill, tachycardia and bounding pulse, warm extremity.(warm shock) Shock

31. Diagnosis Shock is a clinical diagnosis based on a thorough history and physical examination Laboratory Findings : CBC RBS Culture Lactate ABG RFT - Serum creatinine >0.5 mg/dL/2xULN/2xbaseline Shock

32. Cont... PT,PTT,INR - INR >1.5 or aPTT >60 sec LFT - Total bilirubin ≥4 mg/dL ,ALT- 2× ULN EKG,ECHO CXR Shock

33. MANAGEMENT OF PEDIATRIC SHOCK Shock

34. Fundamentals of shock management Optimizing oxygen content of the blood Improving volume and distribution of cardiac output Reduction in oxygen demand Correction of metabolic derangements Shock

35. Components of general management of shock Airway and breathing (ABCs of life) Vascular access Fluid resuscitation Monitoring Lab studies Medical therapy Shock

36. Hypovolemic shock Infusion of fluid (Normal Saline or colloid) Assess for adequacy of treatment For non-malnourished 20ml/kg fast, can be repeated if no response up to 3 to 4 times If needed repeat the bolus with maximum tolerated dose being 60 – 80 ml/kg with in the first 1 – 2 hr. For malnourished children 15ml/kg over 1 hour If due to hemorrhage, transfusion of packed Red Blood Cells (RBC) or whole blood 20ml/kg over 4 hrs. , repeated as needed until Hgb level reaches 10gm/dl and the vital signs are corrected. Shock

37. Fluid resuscitation in increments of 20 mL/kg should be titrated to normalize HR (according to age-based HRs) Urine output (to 1 mL/kg/hr) Capillary refill time (to <2 sec), and Mental status If shock remains refractory following 60-80 mL/kg of volume resuscitation, vasopressor therapy Shock

38. Cardiogenic shock First line • Dobutamine , 2.5-40 micrograms/kg/min IV diluted in dextrose 5%. Never initiate Dobutamine alone in a patient with cardiogenic shock and Systolic BP< 70 OR • Adrenaline, I.V. infusion: Initial: 0.1-0.5 mcg/kg/minute ( 7-35 mcg/minute in a 70 kg patient); titrate to desired response Norepinephrine (noradrenaline), Initial: 0.5-1 mcg/minute and titrate to desired response; 8-30 mcg/minute is usual range. Goal: MAP>65mmhg • Dopamine, 5-20mcg/kg/min IV diluted with dextrose 5% in Water, or in sodium chloride solution 0.9 %; Shock

39. Distributive shock These patients may benefit temporarily from volume resuscitation, but early initiation of a vasoconstrictive agent to increase SVR is an important element of clinical care. Patients with spinal cord injury and spinal shock may benefit from either phenylephrine or vasopressin to increase SVR. Epinephrine is the treatment of choice for patients with anaphylaxis. Shock

40. Anphylactic shock managment Control life threatening cardiopulmonary problems Reversal or blockage of mediators release Fluid bolus Vasopressor : epinephrine Antihistamines C orticosteroid Shock

41. Resuscitation goals Mean arterial pressure > 65 mm Hg Urine output > 0.5 mL/kg/hour Central venous pressure (CVP) 8–10 mm Hg ScvO₂ > 70% Shock

42. Give o2 and establish IV line access and begin resucitation Consider ABG/VBG,lactate,glucose,ionized calcium,cultures, CBC In the first 1 hr push repeatedly 20mL/kg boluses of isotonic crstalloid fluid to rx shock unless rales ,hepatomegaly,respiratory distress develops Shock

43. Additional therapies C orrect hypoglycemia and hypocalcemia A dminister first dose antibiotics STAT C onsider ordering vasopressor drop and hydrocortisone E stablish 2 nd vascular line if vasoactive infusion anticipated Shock

44. Neonates ampicillin plus cefepime and/or gentamicin Neisseria meningitidis,Haemophilus influenzae treated empirically with a third-generation cephalosporin (e.g., ceftriaxone, cefepime) Resistant Streptococcus pneumoniae MRSA Vancomycin Intraabdominal process is suspected metronidazole, clindamycin, or piperacillin-tazobactam Nosocomial sepsis a third- or fourth-generation cephalosporin or a penicillin with an extended gram-negative spectrum (e.g., piperacillin-tazobactam). Indwelling medical device Vancomycin Acyclovir should be added if herpes simplex virus suspected clinically For selected immunocompromised patients Empirical coverage for fungal infections

45. Obstructive shock Ductal dependent Tension pneumothorax Cardiac tamponade Pulmonary embolism Prostaglandin E1 Needle compression pericardiocentesis thrombolytic, anticoagulants Expert consultation Tube thoracotomy 20ml/kg NS/RL bolus 20ml/kg NS/RL bolus Expert consultation Shock

46. Prognosis In septic shock, mortality rates are as low as 3% in previously healthy children and 6–9% in children with chronic illness (compared with 25–30% in adults). With early recognition and therapy, the mortality rate for pediatric shock continues to improve. Shock

47. The risk of death involves a complex interaction of factors, including the underlying etiology, presence of chronic illness, host immune response, and timing of recognition and therapy Shock

48. References Nelson text book of pediatrics 21 st ed STG guideline 4 th ed

49. thank you !