1. Hypoperfusion and Shock
Welcome. This lesson on hypoperfusion and shock is part of the NAEMT Emergency Pediatric Care Course.

2. Hypoperfusion Common problem Extent makes resuscitation difficult
Shock due to hypoperfusion
Start fluid resuscitation as soon as possible
Hypoperfusion is a common problem in the pediatric population. The extent of the shock can make resuscitation difficult. This child is in shock due to hypoperfusion. Fluid resuscitation should be started as soon as possible.

3. Overview
Describe differences between compensated and uncompensated shock
Review differences of distributive, non-distributive and obstructive shock
Explore pathophysiology for different etiologies of shock
Discuss interventions for early and late shock
This lesson will discuss how children in shock or a hypoperfusion state present differently than an adult. It will also: Describe the differences between compensated and uncompensated shock. Review the differences between various categories of shock including distributive, non-distributive and obstructive. Explore the variable pathophysiology for different etiologies of shock. And discuss interventions for early and late shock.

4. Physiology BP = Cardiac Output x Systemic Resistance
Cardiac Output = Stroke Volume x Heart Rate
After-load = Resistance to blood being ejected
Pre-load = Blood returned to heart
Starling’s Law = Amount of cardiac muscle stretch
A review of physiology is needed to help understand how children respond to shock. Blood pressure is a measurement of cardiac output times systemic resistance. Cardiac output is determined by multiplying stroke volume – the amount of blood ejected from the heart with each beat – by the heart rate. The amount of blood ejected from the heart during contraction is determined by: the amount of blood returned to the heart – which is called pre-load, the amount of stretch the cardiac muscles have – which is Starling’s law, and the amount of resistance to the blood being ejected from the heart by the vessels it will enter – which is called after-load.
LifeART
NHTSA

5. Shock Compensation Children vs. Adults
Increased heart rate
Vasoconstriction
Prolonged compensation
Rapid decompensation
Adults
Increased stroke volume
Vasoconstriction
Tachycardia
Slow, but sustained compensation
The body attempts to keep oxygen perfusion and circulation to its vital areas. Children will compensate differently than adults in an attempt to maintain this perfusion. Children first become tachycardic and then their blood vessels vasoconstrict. This massive vasoconstriction is the predominate compensatory mechanism for children. Due to intact compensatory mechanisms, children will compensate for a longer period of time than adults, but their decompensation will be rapid. By contrast, adults initially increase stroke volume, then vasoconstrict, and finally become tachycardic. Thus adults have a slow but sustained compensation response until decompensation. Adult’s compensatory mechanisms are often impaired by a history of cardiac problems.
EPS411.com

6. Categories of Shock Non-Distributive
Hypovolemic
Hemorrhagic
Metabolic
Categories of shock include non-distributive shock due to hypovolemia either due to hemorrhage or metabolic losses such as vomiting and diarrhea.

7. Categories of Shock Distributive
Anaphylaxis
Septic
Neurogenic
Distributive shock includes:
Anaphylactic shock – systemic response from an allergic reaction
Septic – profound reaction to sepsis with a systemic vasodilatation
Neurogenic – involving a disruption of the sympathetic response of the body resulting in vasodilatation below the injury site

8. Categories of Shock Obstructive
Pulmonary embolus
Tension pneumothorax
Cardiac tamponade
Obstructive shock includes:
Pulmonary emboli
Tension pneumothorax – due to impaired cardiac output, requires needle decompression and chest tube placement
Cardiac tamponade due to the collection of fluid in the peicardial sac, limiting the stroke volume ejected from the heart, requires cardiocentesis

9. Etiologies of Hypoperfusion (Common)
Emesis and diarrhea
Osmotic diuresis from diabetes
Internal or external blood loss
Plasma loss from sepsis or anaphylaxis
These are common causes of shock in pediatric patients due to a decrease in circulating blood volume. Hypovolemia will initially require fluid resuscitation to correct losses and restore perfusion.

10. Etiologies of Hypoperfusion (Uncommon)
Spinal cord injury
Cardiac failure
Spinal cord injury and cardiac failure are uncommon causes of shock. A good assessment and a high index of suspicion are required to determine that spinal cord injury or cardiogenic shock is the cause of the hypoperfusion. Fluid boluses may be given initially depending upon how the patient presents, but usually these types of shock require presser medications to restore perfusion and oxygenation to the tissue.
Medications required to restore perfusion

11. Severity of Hypoperfusion Compensated
Decompensated
Signs are due to inadequate tissue perfusion
Volume
Signs of compensated shock in children are due to inadequate tissue perfusion that initiates the body’s compensatory mechanisms in an attempt to maintain perfusion and blood pressure. If shock is identified in this stage, it is often reversible with aggressive fluid therapy.
Compensated shock is reversible with fluids
Time

12. Severity of Hypoperfusion Compensated Shock Signs
Decompensated
Volume
Pulse
Breathing
Blood
Pressure
Signs of compensated shock are due to a sympathetic response. There is an initial increase in respiratory rate to increase oxygenation to the tissues. The heart rate increases and there is a delay in capillary refill – but remember, a cold environment also can cause a delay in capillary refill. Peripheral pulses become weak and the extremities become cool. If a blood pressure is obtained, it will be normal during the compensated stage. One of the first changes noted will be a change in mental status, with an awake patient becoming irritable and/or anxious.
AVPU
Altered Mental Status
Time

13. Severity of Hypoperfusion Compensated Shock Signs
Decompensated
Decompensated
Weak or absent peripheral pulses, weak central pulses
Volume
Weak peripheral pulses, strong central pulses
A quick way to determine if the pediatric shock patient is in compensated versus decompensated shock is by assessing pulses. Peripheral pulses and central pulses should be checked at the same time in order to compare strength. Weak peripheral pulses but strong central pulses equals compensated shock. Weak peripheral pulses or absent peripheral pulses and weak central pulses equals decompensated shock.
Time
EPS411.com

14. Severity of Hypoperfusion Dehydration Testing
This is an image of dehydration testing that involves pulling on and releasing a child’s skin. A normovolemic patient’s skin will quickly return to normal after being released. A hypovolemic patient’s skin will “tent” or remain in the folded position after it is released, as shown in image two.
Hypovolemic patient’s skin will “tent”

15. Severity of Hypoperfusion Decompensated Shock
Inadequate tissue perfusion to all organs
Volume
Decompensated shock results from the body’s inability to continue to compensate for the continued shock state. The result is inadequate tissue perfusion to all organs including the vital organs – such as the heart, lungs, liver and kidneys – that were initially protected by compensatory mechanisms.
Body is unable to continue compensation
Time

16. Severity of Hypoperfusion Decompensated Shock Signs
Volume
Pulse
Breathing
Blood
Pressure
Signs of decompensated shock show the changes the body experiences as it progresses toward death. If the shock state is not reversed, death is the end product. The patient’s level of consciousness progresses to lethargy, responsive to verbal stimulus, then pain stimulus, unresponsive, and then to death. Tachycardia increases and then progresses to bradycardia. Tachypnea increases and becomes bradypnea. Pulses become weak or absent both peripherally and centrally. Capillary refill becomes markedly delayed or absent. Extremities become cool, pale or mottled. Finally there is a downward change in blood pressure called hypotension.
AVPU V P U
Altered Mental Status
Weak or absent peripheral pulses, weak central pulses
Time

17. Severity of Hypoperfusion Decompensated Shock Signs
This is an image of a decompensated toddler. Some signs of decompensated shock seen in this image include: Decreased level of consciousness and pale, cool or mottled extremities. Health care providers are shown taking aggressive measures to restore perfusion to vital organs.

18. Assessment
Assessment begins with a scene survey and forming a general impression of the child using the pediatric assessment triangle.

19. Hazards to you, your partner, the patient and bystanders
Scene Survey
The Scene Survey is the first part of every call. Look for hazards to you, your partner, the patient and bystanders.
Hazards to you, your partner, the patient and bystanders

20. First Impression Pediatric Assessment Triangle
Compensated or decompensated
The first impression using the pediatric assessment triangle is made while approaching the child. Decompensated children will appear ill while compensated children will have more subtle signs and symptoms.
EPS411.com

21. First Impression General Appearance
Observe interactions
Not sick - attentive to environment, focus on familiar people and objects, alert for threats
Good brain function requires adequate oxygenation, ventilation, cerebral perfusion
Sick - does not care you are present or recognize parents
The general appearance will tell you whether the child’s physiology is compensated or not. In other words, it tells you if the child is “sick” or “not sick.” Assessing a child’s general appearance mostly involves observing their interactions with the environment. A normal healthy child is attentive to their environment, focusing on familiar people and interesting objects and alert for possible threats. Good brain function requires adequate oxygenation, ventilation, cerebral perfusion and healthy brain tissue. If the child’s interaction with the environment is good, the body is still compensating for the illness or injury well enough to oxygenate, ventilate and perfuse the brain. If the child does not care that you are present or does not recognize its parents, you should be concerned that the child is decompensated.

22. First Impression General Appearance
Muscle tone
Spontaneous movements
Skin color
Other signs of distress
General appearance also includes a quick survey of the child’s muscle tone and spontaneous movements, the overall color of their skin and mucus membranes, and other signs of distress such as abnormal positions of comfort. A child who’s limp and not moving, who is pale or has cyanosis, or who is maintaining a tripod or other abnormal position is probably sick.
KyleDavidBates.com

23. First Impression Work of Breathing
The work of breathing side of the triangle looks at and helps the PAT provide specificity because it can tell you if respiratory function is also a problem.

24. Skin color, capillary refill, distal vs. central pulses
First Impression Circulation to the Skin
The Circulation to the Skin side of the PAT also lends the tool “specificity” because it tells us if one of the main physiologic malfunctions is in the circulatory system. One of the earliest compensatory mechanisms for decreased circulation is peripheral vascular constriction, as reflected by skin color and temperature, capillary refill and distal versus central pulse quality.
Skin color, capillary refill, distal vs. central pulses

25. First Impression Sick Not Sick Rapid Initial Assessment
Significant MOI?
Rapid Initial Assessment
Yes No
Appropriate Interventions
Relationship
Use the first impression findings to determine “How sick” and “How quick?”
Transport Priority
Involve Family
Transport Method
Detailed History
Transport Destination
Focused Physical Exam

26. Initial Assessment Airway
Loss of airway may occur in decompensated shock
The purpose of the initial assessment is to identify and immediately treat life threats. Remember that as level of consciousness changes – which is driven by brain perfusion – the ability to protect the airway is diminished. Airway protection may be required for pediatric shock patients.
Identify and treat life threats

27. Initial Assessment Breathing
Assess for chest trauma
Abnormal sounds
Rate effort and volume
To ensure adequate oxygenation and ventilation, breathing needs to be fully assessed during the initial assessment. Look at the child’s breathing rate, effort and tidal volume. Listen for abnormal breath sounds. Remember that chest trauma can cause shock – so assess for a tension pneumothorax and for cardiac tamponade if there is a possible mechanism. Treat hypoxia with high flow oxygen and treat any identified causes of respiratory distress with the tools and training you have.
Administer O2 and
treat cause

28. Initial Assessment Circulation
Compensated
Weak peripheral pulses, strong central pulses
Assessment of circulation includes the comparison of central versus peripheral pulses. The quality of these pulses will indicate whether the child is in compensated or decompensated shock. Weak peripheral pulses but strong central pulses equals compensated shock. Weak peripheral pulses or absent peripheral pulses and weak central pulses equals decompensated shock. Capillary refill is an indicator of tissue perfusion and should be assessed, but it may not be accurate in a cold environment or in specific patient. During a rapid head-to-toe exam, look for signs of internal bleeding and external hemorrhage or bleeding. Immediately apply pressure to severe external bleeding.
Decompensated
Weak or absent peripheral pulses, weak central pulses
EPS411.com
EPS411.com

29. Initial Assessment Circulation Management – Intravenous
Fluid bolus if any signs of shock
Early recognition of hypoperfusion and fluid resuscitation are key
Select a large bore catheter
Location close to central circulation
Two IVs may be needed
IV access is only indicated if the child presents with any signs of shock. If there are subtle changes in vital signs such as tachycardia and tachypnea and a high index of suspicion of shock, a fluid bolus should be given and the patient should be reassessed for shock. Early recognition of hypoperfusion and fluid resuscitation are the key to preventing compensated shock from progressing to decompensated shock. For an IV, select a large bore catheter and a location close to central circulation. Two IVs may be needed to adequately fluid resuscitate the child.

30. Initial Assessment Circulation Management – Intraosseous
An IO can be used in any age child – even if they are awake. An IO is easy to use and can rapidly achieve vascular access with a high success rate.
Can be used on any age child

31. Intraosseous Space Blood Flow
The intraosseous space is a specialized area of the vascular system that is often referred to as a non-collapsible vein. Blood flow is steady and generally continues even in shock. Pressure in the IO space – which can be monitored with a pressure transducer – is approximately one-third of systemic pressure. We can withdraw bone marrow from the IO space but generally cannot deposit anything permanently into the marrow because it gets washed out with the blood flow. During IO infusions, we deliver fluid and medication into the vascular system through the intraosseous space, thus the term “IO Vascular Access.”

32. Anatomy Neonate Leg Cross Section
Skin
Subcutaneous
Fat
Intraosseous
Catheter
Tibia
Fibula
Posterior
Compartment
Anterior
Lateral
You can also see the various compartments that can be compressed or filled should fluid be inadvertently infused in the incorrect area. This leakage – or extravasation – can lead to compartment syndrome.

33. Other Issues IO Insertion
Depth based on patient size and weight
Gently insert catheter
Advance catheter slowly
Feel needle drop into medullary space
Frequently monitor insertion site and extremity
Need hands-on training
The decrease in circulation to a distal area secondary to compartment syndrome may cause significant injury. For this reason it is imperative to: Plan placement depth based upon patient size and weight. Gently insert the catheter – do not use excessive force or speed. Advance the catheter slowly – allow the driver to do the work. Feel the needle set tip drop into the medullary space – stop when you feel the pop. Frequently monitor the insertion site and extremity for the signs and symptoms of extravasation or compartment syndrome. Gently and slowly advance the catheter to place the IO needle tip into the medullary space. Use control and precision to avoid serious complications! Do not attempt IO insertion without proper hands-on training from a qualified instructor using appropriate training equipment and simulators.

34. IO Insertion Anatomical Landmarks
Patella
Tibial
Tuberosity
Three important anatomical landmarks for IO insertion are visible in this image: the patella, the flat aspect of the medial tibia, and the tibial tuberosity – if present. Remember that the tibial tuberosity is not prominent in infants and young children.
Medial
Tibia

35. IO Insertion Unable to Palpate Tibial Tuberosity
Here is something important to remember: The tibial tuberosity is often difficult or impossible to palpate on very young patients! The IO insertion site for small patients – where the tibial tuberosity cannot be palpated – is “two finger widths below the patella and then medial along the flat aspect of the tibia.”
Finger Width
Finger Width
Often difficult or impossible to palpate

36. IO Insertion Able to Palpate Tibial Tuberoisty
The IO insertion site for more mature patients – where the tuberosity can be palpated – is “one finger width distal to the tibial tuberosity along the flat aspect of the medial tibia.”
Finger Width

37. Anatomy Neonate Leg Cross Section
Traditional IO Catheter
Tibia
Fibula
Initiating an IO in a neonate is significantly different than placing one in a school-aged child. Note the small intraosseous space, the thin bone density, and the lack of a tibial tuberosity lateral to the insertion site. Now let’s compare the density of relatively small patient weighing approximately 2 kg to that of a much larger patient weighing approximately 35 kg.
Left Leg

38. Anatomy 11 y.o. Tibia Cross Section
Insertion Site
Tibia
Fibula
In the school-aged child, it is easy to appreciate the tibial tuberosity. Also note the larger intraosseous space, the thicker bone density and the tuberosity lateral to the insertion site.
Left Leg

39. Pain Somatic and Visceral
It is important to discuss pain as it relates to IO usage. Preconceived or misinformed viewpoints can lead to inappropriate use and possible complications. There are two types of pain to consider with IO insertion – somatic and visceral. Somatic pain is the pain you feel on the surface of your body while visceral pain is the pain you feel internally.

40. Initial Assessment Circulation Management – Crystalloids
A fluid bolus is required to increase perfusion in the pediatric shock patient. Crystalloids – like normal saline or lactated ringers – are the fluid of choice, but follow your protocols on which fluid to use. Administer 20ml/kg of fluid rapidly – in less than 20 minutes. After each bolus, reassess circulation – central and peripheral pulses, capillary refill and skin parameters – to evaluate the need for additional boluses. Most pediatric shock protocols will allow up to three fluid boluses to be given prehospitally.
20 mL/kg, < 20 minutes
Reassess patient after each fluid bolus

41. Initial Assessment Never Administer D5W
D5W never should be used for fluid boluses because every 100 milliliters of D5W contains 5 grams of dextrose. Utilizing D5W can lead to hyperglycemia.
D5W can lead to hyperglycemia

42. Initial Assessment Circulation Management – Medications
Sepsis
Pressers and antibiotics
Cardiogenic Shock
Pressers, furosemide, morphine and antiarrhythmics
Hypoperfusion in children rarely requires medications for treatment. Nonetheless, the medications that might be administered for several types of shock include: Pressers and antibiotics for sepsis. Pressers, lasix, morphine and antiarrhythmics for cardiogenic shock. Epinephrine, Benadryl and Solu-Medrol for treatment of anaphylaxis.
Anaphylaxis
Epinephrine, diphenhydramine, Solu-Medrol
EPS411.com

43. Initial Assessment Circulation Management – Medications
If medications are given to treat hypoperfusion, it is after fluid boluses have been given with little result. Either epinephrine or dopamine are given to cause vasoconstriction and to improve stroke volume.
Use medications after fluid boluses
EPS411.com

44. Rapid transport for pediatric shock patients
Transport Decision
The final step of the initial assessment is making a transport decision. Patients presenting with either compensated or decompensated shock need to be transported rapidly for emergency department evaluation and to continue treatment therapies. Complete further patient assessment and additional therapies en route to the receiving facility.
Rapid transport for pediatric shock patients

45. Focused History Questions to Determine Type of Shock
Bleeding
Vomiting
Diarrhea
Fluid intake / urine output
As time allows, ask specific focused history questions to help determine the type of shock the patient is experiencing. To determine if the shock is hypovolemic, ask history questions about bleeding, vomiting, diarrhea and if the child is urinating or drinking normally. Check for a fever if you suspect sepsis. Signs of anaphylaxis include bites, stings, hives and swelling, and facial, lip and mouth swelling.
Fever
Anaphylaxis signs
FEMA Photo Library / Andrea Boomer

46. Head to Toe Physical Exam Done En Route
The head-to-toe physical exam should be done en route to the hospital on all patients showing signs of shock.

47. Ongoing Assessment Done Frequently
Reassessment should be done frequently and after every fluid bolus.

48. Summary Recognition and rapid intervention are keys to treatment
Pulse quality and level of consciousness are key indicators
Obtain IV or IO access if shock treatment is needed
Deliver crystalloid fluids at 20 mL/kg
In summary, prehospital providers need to have a high index of suspicion of shock due to history and mechanism of injury. Early recognition and rapid interventions are the key in treating shock and preventing the patient from becoming decompensated. Assessment of pulse quality and level of consciousness are key indicators of shock. Only obtain IV or IO access if shock treatment is needed. Deliver crystalloid fluids for fluid resuscitation at a rate of 20 milliliters per kilogram.