1. Recognizing Shock

2. Objectives Know the definition of shock
Recognize the signs & symptoms of shock
Recognize that there are different types of shock
Discuss interventions/treatment of shock
Understand the differences in neonates

3. What is Shock?
Shock is a clinical state in which the delivery of oxygen and substrates is insufficient to meet the demands of the body

4. What is Shock? DEATH What are the results of shock?
Tissue hypoxia/cellular dysfunction
Metabolic acidosis
Organ dysfunction/failure
DEATH

5. What is Shock? For each hour that shock persists without
treatment, the mortality rate
goes   !

6. What is Shock?
In most cases of shock, the patient’s cardiac output is insufficient to adequately perfuse the body’s organs.

7. What is Shock? Goals in treating shock Restore intravascular volume
Treat any myocardial dysfunction
Treat vascular insufficiency
In order to
↓ HR and ↑ BP
Improve perfusion
↓ metabolic acidosis
↑ urine output

8. Signs and Symptoms of Shock
ASSESSMENT PARAMETERS
General appearance
Capillary refill
Pulses
Vital signs
Urine output
Questions to ask

9. Signs and Symptoms of Shock
General Appearance
What does the patient look like?
Evaluate mental status

10. Signs and Symptoms of Shock
Capillary Refill
Evaluate skin perfusion by checking capillary refill and skin color
Capillary refill is evaluated by positioning the extremity just above the heart level, pressing a finger on the palm of the hand or the bottom of the foot, letting go and then counting how long it takes the color to return to the extremity
Interpret capillary refill in conjunction with other signs of shock as it is a poor indicator when used alone

11. Signs and Symptoms of Shock

12. Signs and Symptoms of Shock
Is this a sign of poor perfusion?

13. Signs and Symptoms of Shock
YES !!!!!

14. Signs and Symptoms of Shock
Pulses
Evaluate pulses

15. Signs and Symptoms of Shock
How do you compare pulses???
Palpate peripheral & central pulses & compare
Femoral & Pedal Or
Brachial and Radial
Are they ?
Weak /Thready
Normal
Bounding
Absent
Note: A patient will lose peripheral pulses before they lose central pulses

16. Signs and Symptoms of Shock
Vital Signs
Evaluate vital signs
They are called vital signs because…..

17. …….they are REALLY, REALLY important!!!!!
Signs and Symptoms of Shock
…….they are REALLY, REALLY important!!!!!

18. Signs and Symptoms of Shock
In order for vital signs to be helpful you need to know
Absolute number
Context or clinical scenario
Trends

19. Signs and Symptoms of Shock
Absolute number
Is the number normal or abnormal?

20. Signs and Symptoms of Shock
Context
What is the child doing?
(i.e., sleeping, playing, etc.)
What is the clinical condition the child is in? (i.e., dehydration, fever, anemia, hypoxia, pain, anxiety, etc.)

21. Signs and Symptoms of Shock
Trends
Are the vital signs:
Improving?
Stable?
Deteriorating?

22. Signs and Symptoms of Shock
Stable means
Unchanging or static
It does not automatically mean normal or good
Remember, death is a stable state!

23. Signs and Symptoms of Shock
HEART RATE
You must evaluate the heart rate in the context and clinical state of the child.
Is he running around ?
Is he febrile?
Is he crying?

24. Signs and Symptoms of Shock
HEART RATE
Rate normally decreases as child’s age increases
Tachycardia is the body’s response to stress
Note normal ranges on Vital Sign Reference Sheet (see next slide)

25. PEDIATRIC VITAL SIGNS REFERENCE CHART
AGE
WT.
(KG)
PULSE
RESPIRATORY
RATE
SYSTOLIC BP
DIASTOLIC
BIRTH
100 – 180 35
50 – 70
16 – 36
1 MONTH 4
100 – 220 30
60 – 90
20 – 60
6 MONTHS 7
80 – 150
87 – 105
53 – 66
2 YEARS 25
95 – 105
4 YEARS
70 –110 23
6 YEARS
70 – 110 21
7 YEARS
97 – 112
57 – 71
8 YEARS 20
10 YEARS
55 – 90 19
ADOLESCENT
> 50
115 – 128
 Normal Values:
Systolic BP 1 to 7 years (age in years + 90)
8 to 18 years ( 2 x age in years + 83)
Diastolic BP 1 to 5 years (56)
6 to 8 years ( age in years + 52)

26. Signs and Symptoms of Shock
HEART RATE
CO = HR X SV
CO = cardiac output (volume of blood ejected by the heart each minute)
HR = heart rate
SV = stroke volume (volume of blood ejected per beat)
The body attempts to compensate for a decreasing stroke volume by increasing the heart rate

27. Signs and Symptoms of Shock
BLOOD PRESSURE
Measure systolic BP & diastolic BP
Calculate pulse pressure (sBP – dBP = Pulse Pressure)
Why?… It is important to identify a widened pulse pressure because it may be an early sign of shock.
If you wait to respond, it may result in a decrease in BP & narrow pulse pressure
Documenting “unable to obtain ” when measuring BP is unacceptable

28. Hemodynamic Response to Shock
140
100 60 20
Vascular Resistance
BP = CO x VR
As the CO ↓ the HR & VR ↑
This enables the body to
maintain a normal BP
THIS IS A KEY DIFFERENCE
BETWEEN CHILDREN & ADULTS
Percent of control
Slide 11: Hemodynamic Response to Shock in Infants and Children
This figure illustrates typical changes in heart rate, blood pressure, and cardiac output as the child moves from compensated to decompensated (ie, hypovolemic to hypotensive) shock.
Note that tachycardia without hypotension is present in compensated shock. Blood pressure is initially maintained through an increase in systemic vascular resistance.
As cardiac output falls further, blood pressure begins to fall, and shock is characterized as decompensated shock.
Cardiac Output
Blood Pressure
Decompensated
or Late Shock
Compensated
or Early Shock

29. Signs and Symptoms of Shock
BLOOD PRESSURE
Hypotension typically develops before loss of central pulses
Hypotension is an ominous sign. If it is not treated promptly it will lead to cardiopulmonary failure/arrest

30. Signs and Symptoms of Shock
Urine Output
Evaluate urine output
Urine output is a good indicator of renal perfusion, but do not use the initial measurement of urine

31. Signs and Symptoms of Shock
How to calculate normal urine output

32. Signs and Symptoms of Shock
Assessment Questions
Does my patient have normal perfusion?
What is the capillary refill?
How do the central and peripheral pulses compare?
What is the HR and BP? Is the patient improving?
What is my patient’s mental status?
Is my patient urinating? Is it adequate?

33. Types of Shock Hypovolemic Shock Cardiogenic Shock Neurogenic shock
– inadequate intravascular volume - most common
Cardiogenic Shock
- characterized by myocardial dysfunction
Neurogenic shock
– characterized by nervous system dysfunction
Anaphylactic shock
– life threatening exposure to an allergen

34. Types of Shock Septic shock has three components:
Systemic inflammatory response
Infection
Poor perfusion and hypotension

35. Types of Shock Systemic Inflammatory Response Syndrome
> 2 of the following:
Abnormal temperature
Tachycardia
Tachypnea or respiratory alkalosis
Abnormalities of WBC

36. Types of Shock PHYSIOLOGIC CLASSIFICATION OF SHOCK EARLY LATE
Signs of inadequate tissue/organ perfusion
Normal BP
LATE
Signs of inadequate tissue and/or organ perfusion
Hypotension

37. Types of Shock Irreversible Shock
Complete failure of the body’s compensatory mechanisms
Death occurs even in the presence of resuscitation measures

38. Types of Shock Early Shock
What will the body do to try and compensate?

39. Types of Shock Have a catecholamine surge which results in….
Tachycardia
↑↑ systemic vascular resistance
Cool, pale, mottled skin
Capillary refill > 2 seconds
Weak, thready peripheral pulses

40. Types of Shock What else ? Blood pressure changes
Increased respiratory rate
Patient may be irritable, sleepy, lethargic
May see a decrease in urine output
Blood pressure changes
Systolic is normal or even high
Diastolic may be low

41. Types of Shock Late/Decompensated Shock
Defense mechanisms begin to fail
The patient may exhibit:
Hypotension
Prolonged capillary refill
Tachycardia or (bradycardia – ominous sign)
Absent peripheral pulses
Rapid, thready central pulses
Decreased level of consciousness

42. Interventions/Treatments
Provide O2 and mechanical ventilation
FLUID RESUSCITATION
20ml/kg NS boluses (note the plural)
Vasoactive infusions (ie. dopamine)
Treat metabolic abnormalities

43. Interventions/Treatments
Clinical Strategies
Know your patient’s history
Know normal vs abnormal and look for abnormalities
Know your patient’s vital sign trends
Think the “worst case scenario” and then rule it out

44. Interventions/Treatments
Clinical Pearls
Know and look for these early warning signs
↑HR - the most commonly ignored abnormal vital sign is tachycardia
Peripheral perfusion abnormalities
dBP – look for diastolic hypotension and look at the pulse pressure

45. Interventions/Treatments
You MUST do FREQUENT, RAPID REASSESSMENTS of the patient’s hemodynamic status and DOCUMENT everything!

46. Neonates
If children are different from adults, then neonates are something else entirely.

47. Neonates Differences in the neonate
We are talking about patients with an
age of < 28 days
Limited cardiac reserve
Limited respiratory reserve
Limited metabolic reserve

48. Neonates Take home message for neonates………
Neonates can go into a shock state faster than children and adults.
Neonates have less tolerance for shock states than children and adults.
You must identify and treat shock immediately!

49. Message from Dr. Hernan Recognize shock and label it
Rapidly and repeatedly assess hemodynamics
Mortality is related to persistent shock
Be appropriately aggressive with fluids and vasoactive infusions
Intubate and mechanically ventilate early
Remember the neonate
Jump start the circulation or patients die

50. SHOCK – Reference Chart
EARLY
LATE
Respiratory
Rate
Increased
Bradypnea - ominous
Heart Rate
Bradycardia - ominous
Pulse Quality
Decreased to thready
Bounding in Septic
Peripheral pulse may be absent Central decreased
Capillary Refill
Prolonged >2 seconds
Prolonged
LOC
Normal to altered
Altered mental status BP
Normal
Hypotensive
Urine Output
Decreased
Anuric

51. REFERENCES: Carcillo JA: Task force Members, Fields al
REFERENCES: Carcillo JA: Task force Members, Fields al. Clinical practice Parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 30(6):1-13, Hernan, Lynn J., MD, “Vital Signs” , “Recognition and Treatment of Pediatric Shock” Kaleida Health Corporate Nursing Policy, Pediatric Vital Signs. PED.5PTC PALS Provider Manual (2002). American Heart Association, Dallas, Texas AHA, PALS Instructor Manual, Whaley, Lucille F. and Wong, Donna L. (2003). Nursing Care of Infants and Children, 7th Edition, C.V. Mosby Company, St. Louis