1. Pediatric Shock Recognition, Classification and Initial Management
Critical Concepts Course

2. Introduction
Shock is a syndrome that results from inadequate oxygen delivery to meet metabolic demands
Oxygen delivery (DO2 ) is less than Oxygen Consumption (< VO2)
Untreated this leads to metabolic acidosis, organ dysfunction and death

3. Oxygen Delivery
Oxygen delivery = Cardiac Output x Arterial Oxygen Content
(DO2 = CO x CaO2)
Cardiac Output = Heart Rate x Stroke Volume (CO = HR x SV)
SV determined by preload, afterload and contractility
Art Oxygen Content = Oxygen content of the RBC + the oxygen dissolved in plasma
(CaO2 = Hb X SaO2 X (.003 X PaO2)

5. Stages of Shock Compensated
Vital organ function maintained, BP remains normal.
Uncompensated
Microvascular perfusion becomes marginal. Organ and cellular function deteriorate. Hypotension develops.
Irreversible

6. Clinical Presentation
Early diagnosis requires a high index of suspicion
Diagnosis is made through the physical examination focused on tissue perfusion
Abject hypotension is a late and premorbid sign

7. Initial Evaluation: Physical Exam Findings of Shock
Neurological: Fluctuating mental status, sunken fontanel
Skin and extremities: Cool, pallor, mottling, cyanosis, poor cap refill, weak pulses, poor muscle tone.
Cardio-pulmonary: Hyperpnea, tachycardia.
Renal: Scant, concentrated urine

8. Initial Evaluation: Directed History
Past medical history
heart disease
surgeries
steroid use
medical problems
Brief history of present illness
exposures
onset

9. Differential Diagnosis of Shock
Cardiogenic
Myocardial dysfunction
Dysrrhythmia
Congenital heart disease
Obstructive
Pneumothorax, CardiacTamponade, Aortic Dissection
Dissociative
Heat, Carbon monoxide, Cyanide
Endocrine
Hypovolemic
Hemorrhage
Fluid loss
Drugs
Distributive
Analphylactic
Neurogenic
Septic

10. Differential Diagnosis of Shock
Precise etiologic classification may be delayed
Immediate treatment is essential
Absolute or relative hypovolemia is usually present

11. Include in differential:
Neonate in Shock:
Include in differential:
Congenital adrenal hyperplasia
Inborn errors of metabolism
Obstructive left sided cardiac lesions:
Aortic stenosis
Hypoplastic left heart syndrome
Coarctation of the aorta
Interrupted aortic arch

12. Management-General
Goal: increase oxygen delivery and decrease oxygen demand:
For all children:
Oxygen
Fluid
Temperature control
Correct metabolic abnormalities
Depending on suspected cause:
Antibiotics
Inotropes
Mechanical Ventilation

13. Management-General Airway Breathing Circulation
If not protected or unable to be maintained, intubate.
Breathing
Always give 100% oxygen to start
Sat monitor
Circulation
Establish IV access rapidly
CR monitor and frequent BP

14. Management-General Laboratory studies: ABG Blood sugar Electrolytes
CBC
PT/PTT
Type and cross
Cultures

15. Management-Volume Expansion
Optimize preload
Normal saline (NS) or lactated ringer’s (RL)
Except for myocardial failure use 10-20ml/kg every 2-10 minutes. Reasses after every bolus.
At 60ml/kg consider: ongoing losses, adrenal insufficiency, intestinal ischemia, obstructive shock. Get CXR. May need inotropes.

16. Fluid in early septic shock Carcillo, et al, JAMA, 1991
Retrospective review of 34 pediatric patients with culture + septic shock, from
Hypovolemia determined by PCWP, u.o and hypotension.
Overall, patients received 33 cc/kg at 1 hour and 95 cc/kg at 6 hours.
Three groups:
1: received up to 20 cc/kg in 1st 1 hour
2: received cc/kg in 1st hour
3: received greater than 40 cc/kg in 1st hour
No difference in ARDS between the 3 groups

17. Fluid in early septic shock Carcillo, et al, JAMA, 1991
Group 1
(n = 14)
Group 2
(n = 11)
Group 3
(n = 9)
Hypovolemic at 6 hours
-Deaths 6 2
Not hypovolemic at 6 hours 8 9 5 1
Total deaths 7

18. Inotropes and Vasopressors
Lack of history of fluid losses, history of heart disease, hepatomegaly, rales, cardiomegaly and failure to improve perfusion with adequate oxygenation, ventilation, heart rate, and volume expansion suggests a cardiogenic or distributive component.
Consider Appropriate inotropic or vasopressor support.

19. Hypovolemic Shock Most common form of shock world-wide
Results in decreased circulating blood volume, decrease in preload, decreased stroke volume and resultant decrease in cardiac output.
Etiology: Hemorrhage, renal and/or GI fluid losses, capillary leak syndromes

20. Hypovolemic Shock
Clinically, history of vomiting/diarrhea or trauma/blood loss
Signs of dehydration: dry mucous membranes, absent tears, decreased skin turgor
Hypotension, tachycardia without signs of congestive heart failure

21. Hemorrhagic Shock
Most common cause of shock in the United States (due to trauma)
Patients present with an obvious history (but in child abuse history may be misleading)
Site of blood loss obvious or concealed (liver, spleen, intracranial, GI, long bone fracture)
Hypotension, tachycardia and pallor

22. Hypovolemic/Hemorrhagic Shock: Therapy
Always begin with ABCs
Replace circulating blood volume rapidly: start with crystalloid
Blood products as soon as available for hemorrhagic shock (Type and Cross with first blood draw)
Replace ongoing fluid/blood losses & treat the underlying cause

23. Septic Shock SIRS/Sepsis/Septic shock Mediator release:
exogenous & endogenous
Maldistribution
of blood flow
Cardiac
dysfunction
Imbalance of oxygen
supply and demand
Alterations in
metabolism

24. Septic Shock: “Warm Shock”
Early, compensated, hyperdynamic state
Clinical signs
Warm extremities with bounding pulses, tachycardia, tachypnea, confusion.
Physiologic parameters
widened pulse pressure, increased cardiac ouptut and mixed venous saturation, decreased systemic vascular resistance.
Biochemical evidence:
Hypocarbia, elevated lactate, hyperglycemia

25. Septic Shock: “Cold Shock”
Late, uncompensated stage with drop in cardiac output.
Clinical signs
Cyanosis, cold and clammy skin, rapid thready pulses, shallow respirations.
Physiologic parameters
Decreased mixed venous sats, cardiac output and CVP, increased SVR, thrombocytopenia, oliguria, myocardial dysfunction, capillary leak
Biochemical abnormalities
Metabolic acidosis, hypoxia, coagulopathy, hypoglycemia.

26. Septic Shock
Cold Shock rapidly progresses to mutiorgan system failure or death if untreated
Multi-Organ System Failure: Coma, ARDS, CHF, Renal Failure, Ileus or GI hemorrhage, DIC
More organ systems involved, worse the prognosis
Therapy: ABCs, fluid
Appropriate antibiotics, treatment of underlying cause

27. Cardiogenic Shock Etiology: Dysrhythmias Infection (myocarditis)
Metabolic
Obstructive
Drug intoxication
Congenital heart disease
Trauma

28. Cardiogenic Shock Differentiation from other types of shock: History
Exam:
Enlarged liver
Gallop rhythm
Murmur
Rales
CXR:
Enlarged heart, pulmonary venous congestion

29. Cardiogenic Shock Management: Improve cardiac output::
Correct dysrhthymias
Optimize preload
Improve contractility
Reduce afterload
Minimize cardiac work:
Maintain normal temperature
Sedation
Intubation and mechanical ventilation
Correct anemia

30. Distributive Shock
Due to an abnormality in vascular tone leading to peripheral pooling of blood with a relative hypovolemia.
Etiology
Anaphylaxis
Drug toxicity
Neurologic injury
Early sepsis
Management
Fluid
Treat underlying cause

31. Obstructive Shock Mechanical obstruction to ventricular outflow
Etiology: Congenital heart disease, massive pulmonary embolism, tension pneumothorax, cardiac tamponade
Inadequate C.O. in the face of adequate preload and contractility
Treat underlying cause.

32. Dissociative Shock
Inability of Hemoglobin molecule to give up the oxygen to tissues
Etiology: Carbon Monoxide poisoning, methemoglobinemia, dyshemoglobinemias
Tissue perfusion is adequate, but oxygen release to tissue is abnormal
Early recognition and treatment of the cause is main therapy

33. Hemodynamic Variables in Different Shock States
 or    
Septic: Late 
 Or 


Septic: Early
Distributive
Obstructive
Cardiogenic
Hypovolemic
CVP
Wedge
MAP
SVR CO

34. Recognition and Classification

35. Initial Management of Shock

36. Final Thoughts
Recognize compensated shock quickly- have a high index of suspicion, remember tachycardia is an early sign. Hypotension is late and ominous.
Gain access quickly- if necessary use an intraoseous line.
Fluid, fluid, fluid - Administer adequate amounts of fluid rapidly. Remember ongoing losses.
Correct electrolytes and glucose problems quickly.
If the patient is not responding the way you think he should, broaden your differential, think about different types of shock.

37. References, Recommended Reading, and Acknowledgments
Uptodate: Initial Management of Shock in Pediatric patients
Nelson’s Textbook of Pediatrics
Some slides based on works by Dr. Lou DeNicola and Dr. Linda Siegel for PedsCCM
American Heart Association PALS guidelines