Presentation on theme: "Kids Rock Shock! Recognizing Shock in Children"— Presentation transcript:
1 Kids Rock Shock! Recognizing Shock in Children Jackie Williams-Connolly RNLaila Brown BN, RNJaneway EmergencyOctober 2013
2 What is Shock?Circulatory system failure to supply oxygen and nutrients to meet cellular metabolic demandsResults from inadequate tissue perfusionShock is the most reversible cause of death in children!!!
3 Shock in Pediatrics Types: Hypovolemic Distributive Cardiogenic Obstructive
4 a result of blood and/or body fluid loss Hypovolemic Shock:a result of blood and/or body fluid loss# 1 cause of death in children worldwideCausesWater Loss(diarrhea, vomiting with poor PO intake, diabetes, major burns)Blood Loss(obvious trauma; occult bleeding from pelvic fractures, blunt abdominal trauma, “shaken baby”)
5 A result of excessive vasodilation and Distributive Shock:A result of excessive vasodilation andthe impaired distribution of blood flowCauses:Occurs when the blood vessels dilate, resulting in poor distribution of blood flow or volumeThe vasodilation and venodilation cause pooling of blood in the venous systemMost common forms of distributive shock areSeptic shockAnaphylactic shockNeurogenic shock (spinal injury)
6 Results from ineffective tissue perfusion Cardiogenic Shock:Results from ineffective tissue perfusioncaused by inadequate contraction of the cardiac muscleCauses:Congenital heart diseaseMyocarditis (inflammation of heart muscle)Cardiomyopathy (an inherited or acquired abnormality of pumping function)DysrhythmiasMyocardial injury (trauma)
7 Results from an inadequate circulating blood volume Obstructive Shock:Results from an inadequate circulating blood volumeCauses:Because of a physical obstruction or compression of the great veins, aorta, pulmonary arteries, or the heartCardiac tamponadeTension pneumothoraxMassive pulmonary embolism
8 Hemodynamic definitions of shock Cold ShockDepressed level of consciousnessCapillary refill > 2 secsDiminished peripheral pulsesMottled cool extremitiesDecreased urine outputWarm ShockDepressed level of consciousnessFlash capillary refillBounding peripheral PulsesDecreased urine output
9 Stages of Shock Death Refractory (Irreversible) Hypotensive/ InitialCompensatedHypotensive/DecompensatedRefractory(Irreversible)Death
10 Initial Cardiac output is decreased and tissue perfusion is impaired decrease blood supply (oxygen) to the cellsAnaerobic metabolism decreases energy but increases lactic acidLactic acidemia (metabolic acidosis) quickly causes more cellular damageMinimal changes in Vital SignsNormal BP
11 KEYS to Early Shock Recognition ALTERED MENTAL STATUSIrritable, inconsolableDoes not interact with parentStares into spacePoor response to painABNORMAL PERFUSIONDecreased or bounding peripheral pulsesPoor capillary refillDecreased urine output
12 CompensatoryThe patient in this stage of shock has very few symptoms, and treatment can completely halt any progressionlow blood flow (perfusion) is first detected (Capillary Refill)Multiple systems are activated in order to maintain/restore perfusionHeart rate increases
13 Vasoconstriction-changes in skin color & pulses The kidney works to retain fluid in the circulatory systemAll this serves to maximize blood flow to the most important organs and systems in the bodyBP is not a good indicator:Could still be normalChildren can lose up to 25% of fluid volume before we see a change
14 Hypotensive/Decompensated Methods of compensation begin to failThe systems of the body are unable to improve perfusion any longer, and the patient's symptoms reflect that factOxygen deprivation in the brain causes the patient to become confused and disoriented, while oxygen deprivation in the heart may cause chest painWith quick and appropriate treatment, this stage of shock can be reversed.
15 Refractory/Irreversible the length of time that poor perfusion has existed begins to take a permanent toll on the body's organs and tissuesThe heart's functioning continues to spiral downward, and the kidneys usually shut down completelyCells in organs and tissues throughout the body are injured and dyingComplete failure of compensatory mechanismsDeath even in the presence of Resuscitation
16 WARNING !!! Blood pressure may be normal in early, compensated shock Normal Bp = X age ( 1-10 yrs)Low blood pressure does not occur until LATE shock Tachycardia is a non-specific sign of distress
17 LATE SHOCKVital Signs:TachycardiaTachypneaHypotensionExam Findings:Agitated, confused, decreased LOCPoor toneTacky mucous membranesCool, mottled extremitiesDecreased pulsesDelayed capillary refill, >4 secondsLate Shock is a Pre-arrest State!!
18 Death even in the presence of Resuscitation If symptoms of shock are missedIf treatments are inadequate or delayedShock progression is typically an “accelerating condition”It may take hours for compensated shock to progress to hypotensive shockOnly minutes for hypotensive shock to progress to cardiopulmonary failure and cardiac arrest!
19 Treatment of shock ABC’S IV/IO access ! ( don’t waste valuable time on IV access, IO very practical in kids)Fluids : 20 ml/kg over 5-10 minutes (unless Cardiac involvement is suspected then 5-10 ml/kg always reassess chest sounds/CXR for signs of fluid overload)USE N/S (preferred)or R/L (if no Renal Problems due to K)Too much fluid can cause Cerebral Edema (esp. in DKA)Antimicrobial coverage is essentialSteroids (2MG/KG TO MAX 100MG)Consider inotropic and vasoactive agentsGood History from family (SAMPLE)Always reassess your patient, their treatments and the plan
20 Anti Microbial Treatment is essential to increase survival rates: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock
21 Case Study: 4 month old male, previously well Parents state he has had fever, vomiting and diarrhea for the past two daysToday, extremely fussy and refusing feedsOne wet diaper over the past 12 hours
22 Case Study: Physical Exam Toxic-appearing infant, irritable, does not consoleT-39.6 HR-206 RR-66 BP-129/109Sat probe is not picking up wellTacky mucous membranesSunken fontanelPalpable femoral pulse, thready peripheral pulsesExtremities cool and mottled
23 Case Study: What history is concerning? What exam findings are concerning?What stage of shock is this infant in?What type of shock?How do you start management?
24 Treatment: You place the baby on oxygen You are able to insert a peripheral IVWhat if you can’t get an IV? IO?What fluids and how much?Antimicrobials
25 Treatment & Goals: Reassessment You estimate the baby is 5 kg and give NS 100ml rapidlyInfant still fussy and mottledYou give a second NS bolus of 100mLOn reassessment, somewhat fussy, alertHR-180 RR-30 BP-130/100 O2sat 100% on 100%O2cap refill <2s
27 Reassess, Reassess, Take Home Points: Shock is the most reversible cause of death in childrenBP has little to do with early shock recognitionIt is NOT OK to sit on a patient who has compensated shockLate shock is a pre-arrest stateThe majority types of Shock is fluid responsiveShock is a major cause of morbidity and mortality in pediatric patientsEarly and aggressive management leads to improved outcomes!Reassess, Reassess,
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