2 Objectives Know the definition of shock Recognize the signs & symptoms of shockRecognize that there are different types of shockDiscuss interventions/treatment of shockUnderstand 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 dysfunctionMetabolic acidosisOrgan dysfunction/failureDEATH
5 What is Shock? For each hour that shock persists without treatment, the mortality rategoes !
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 dysfunctionTreat vascular insufficiencyIn order to↓ HR and ↑ BPImprove perfusion↓ metabolic acidosis↑ urine output
8 Signs and Symptoms of Shock ASSESSMENT PARAMETERSGeneral appearanceCapillary refillPulsesVital signsUrine outputQuestions to ask
9 Signs and Symptoms of Shock General AppearanceWhat does the patient look like?Evaluate mental status
10 Signs and Symptoms of Shock Capillary RefillEvaluate skin perfusion by checking capillary refill and skin colorCapillary 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 extremityInterpret capillary refill in conjunction with other signs of shock as it is a poor indicator when used alone
14 Signs and Symptoms of Shock PulsesEvaluate pulses
15 Signs and Symptoms of Shock How do you compare pulses???Palpate peripheral & central pulses & compareFemoral & PedalOrBrachial and RadialAre they ?Weak /ThreadyNormalBoundingAbsentNote: A patient will lose peripheral pulses before they lose central pulses
16 Signs and Symptoms of Shock Vital SignsEvaluate vital signsThey 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 knowAbsolute numberContext or clinical scenarioTrends
19 Signs and Symptoms of Shock Absolute numberIs the number normal or abnormal?
20 Signs and Symptoms of Shock ContextWhat 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 TrendsAre the vital signs:Improving?Stable?Deteriorating?
22 Signs and Symptoms of Shock Stable meansUnchanging or staticIt does not automatically mean normal or goodRemember, death is a stable state!
23 Signs and Symptoms of Shock HEART RATEYou 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 RATERate normally decreases as child’s age increasesTachycardia is the body’s response to stressNote normal ranges on Vital Sign Reference Sheet (see next slide)
25 PEDIATRIC VITAL SIGNS REFERENCE CHART AGEWT.(KG)PULSERESPIRATORYRATESYSTOLICBPDIASTOLICBIRTH100 – 1803550 – 7016 – 361 MONTH4100 – 2203060 – 9020 – 606 MONTHS780 – 15087 – 10553 – 662 YEARS2595 – 1054 YEARS70 –110236 YEARS70 – 110217 YEARS97 – 11257 – 718 YEARS2010 YEARS55 – 9019ADOLESCENT> 50115 – 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 RATECO = HR X SVCO = cardiac output (volume of blood ejected by the heart each minute)HR = heart rateSV = 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 PRESSUREMeasure systolic BP & diastolic BPCalculate 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 pressureDocumenting “unable to obtain ” when measuring BP is unacceptable
28 Hemodynamic Response to Shock 1401006020Vascular ResistanceBP = CO x VRAs the CO ↓ the HR & VR ↑This enables the body tomaintain a normal BPTHIS IS A KEY DIFFERENCEBETWEEN CHILDREN & ADULTSPercent of controlSlide 11: Hemodynamic Response to Shock in Infants and ChildrenThis 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 OutputBlood PressureDecompensatedor Late ShockCompensatedor Early Shock
29 Signs and Symptoms of Shock BLOOD PRESSUREHypotension typically develops before loss of central pulsesHypotension is an ominous sign. If it is not treated promptly it will lead to cardiopulmonary failure/arrest
30 Signs and Symptoms of Shock Urine OutputEvaluate urine outputUrine 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 QuestionsDoes 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 commonCardiogenic Shock- characterized by myocardial dysfunctionNeurogenic shock– characterized by nervous system dysfunctionAnaphylactic shock– life threatening exposure to an allergen
34 Types of Shock Septic shock has three components: Systemic inflammatory responseInfectionPoor perfusion and hypotension
35 Types of Shock Systemic Inflammatory Response Syndrome > 2 of the following:Abnormal temperatureTachycardiaTachypnea or respiratory alkalosisAbnormalities of WBC
36 Types of Shock PHYSIOLOGIC CLASSIFICATION OF SHOCK EARLY LATE Signs of inadequate tissue/organ perfusionNormal BPLATESigns of inadequate tissue and/or organ perfusionHypotension
37 Types of Shock Irreversible Shock Complete failure of the body’s compensatory mechanismsDeath 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 resistanceCool, pale, mottled skinCapillary refill > 2 secondsWeak, thready peripheral pulses
40 Types of Shock What else ? Blood pressure changes Increased respiratory ratePatient may be irritable, sleepy, lethargicMay see a decrease in urine outputBlood pressure changesSystolic is normal or even highDiastolic may be low
41 Types of Shock Late/Decompensated Shock Defense mechanisms begin to failThe patient may exhibit:HypotensionProlonged capillary refillTachycardia or (bradycardia – ominous sign)Absent peripheral pulsesRapid, thready central pulsesDecreased level of consciousness
42 Interventions/Treatments Provide O2 and mechanical ventilationFLUID RESUSCITATION20ml/kg NS boluses (note the plural)Vasoactive infusions (ie. dopamine)Treat metabolic abnormalities
43 Interventions/Treatments Clinical StrategiesKnow your patient’s historyKnow normal vs abnormal and look for abnormalitiesKnow your patient’s vital sign trendsThink the “worst case scenario” and then rule it out
44 Interventions/Treatments Clinical PearlsKnow and look for these early warning signs↑HR - the most commonly ignored abnormal vital sign is tachycardiaPeripheral perfusion abnormalitiesdBP – 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 NeonatesIf children are different from adults, then neonates are something else entirely.
47 Neonates Differences in the neonate We are talking about patients with anage of < 28 daysLimited cardiac reserveLimited respiratory reserveLimited 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 hemodynamicsMortality is related to persistent shockBe appropriately aggressive with fluids and vasoactive infusionsIntubate and mechanically ventilate earlyRemember the neonateJump start the circulation or patients die
50 SHOCK – Reference Chart EARLYLATERespiratoryRateIncreasedBradypnea - ominousHeart RateBradycardia - ominousPulse QualityDecreased to threadyBounding in SepticPeripheral pulse may be absent Central decreasedCapillary RefillProlonged >2 secondsProlongedLOCNormal to alteredAltered mental statusBPNormalHypotensiveUrine OutputDecreasedAnuric
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