2 Objectives Differentiate shock from hypotension Distinguish compensated from decompensated shockOutline appropriate shock managementIdentify and manage selected pediatric dysrhythmias2
3 Shock and HypotensionShock is inadequate perfusion and oxygen delivery.Hypotension is decreased systolic blood pressure.Shock can occur with increased, decreased, or normal blood pressure.22
4 Recognition of Shock Compensated: Decompensated: Normal level of consciousness• Altered level of consciousness (ALOC)• Tachycardia• Profound tachycardia, or bradycardia• Normal or delayed capillary refill time (CRT)• Delayed CRT• Normal or increased BP• Hypotension28
5 Management of Shock Interventions: Open airway Provide supplemental oxygenSupport ventilationShock positionVascular access/fluid resuscitationVasopressor support
6 9-month-old infantA 9-month-old presents with 3 days of vomiting, diarrhea and poor oral intake.
7 9-month-old infant Appearance Work of Breathing Circulation to Skin Agitated, makes eye contactWork of BreathingNo retractions or abnormal airway soundsCirculation to SkinPale skin color
8 Initial Assessment Airway - Open and maintainable Breathing - RR 50 breaths/min, clear lungs, good chest riseCirculation - HR 180 beats/min; cool, dry, pale skin; CRT 3 seconds; BP 74 mm Hg/palpDisability - AVPU=AExposure - No sign of trauma, weight 8 kg11
9 What is this child’s physiologic state? What are your treatment priorities?
10 Treatment priorities: Provide oxygen, as tolerated Assessment: Compensated shock, likely due to hypovolemia with viral illnessTreatment priorities:Provide oxygen, as toleratedObtain IV access en routeProvide fluid resuscitation20 ml/kg of crystalloid, repeat as neededTony - note that oftentimes the status of the child improves dramatically with fluid resuscitation - rare that the child needs any additional therapy nor advanced airway management13
11 160 ml normal saline infused HR decreased to 140 beats/minPatient alert and interactive, receiving second bolus on emergency department arrival
12 15-month-old childA previously healthy 15-month-old child presents with 12 hours of fever, 1 hour of lethargy and a “purple” rash.
13 15-month-old child Appearance Work of Breathing Circulation to Skin No eye contact, lies still with no spontaneous movementWork of BreathingNo retractions or abnormal airway soundsCirculation to SkinPale skin color
14 Initial Assessment Airway - Open Breathing - RR 60 breaths/min, poor chest riseCirculation - HR 70 beats/min; faint brachial pulse; warm skin; CRT 4 seconds; BP 50 mm Hg/palpDisability - AVPU=PExposure - Purple rash, no sign of trauma, weight 10 kg7
15 What is your assessment of this patient? What is her physiologic state?8
16 This patient is in decompensated shock. What are your treatment and transport priorities for this patient?
17 Treatment Priorities Begin BVM ventilation with 100% oxygen. Fluid resuscitation:IV/IO access on scene20 ml/kg of crystalloid, repeat as needed en routeVasopressor therapyTony be sure to emphasize need to fluid resuscitate before beginning pressor agents. We had a discussion on this subject on the conference call - decision made to emphasize that it is difficult to initiate drips such as dopamine for children - consider boluses of epinephrine 1: solution for children in decompensated septic shock after adequate fluid resuscitation 60 mL/kg
18 Patient received 20 ml/kg (200 ml) with no change in level of consciousness, HR or BP. What are your treatment priorities now?
19 Consider endotracheal intubation Provide second 20 ml/kg fluid bolusConsider vasopressor support if prolonged transport time
20 3-year-old toddler Toddler is found cyanotic and unresponsive Child last seen 1 hour prior to discoveryOpen bottle of clonidine found next to child14
21 3-year-old toddler Appearance Work of Breathing Circulation to Skin No spontaneous activity; unresponsiveWork of BreathingGurgling breath soundsCirculation to SkinCyanotic, mottled
22 Initial Assessment Airway - Partial obstruction by tongue Breathing - RR 15 breaths/min, poor air entryCirculation - HR 30 beats/min; faint femoral pulse; CRT 3 seconds; BP 50/30 mm HgDisability - AVPU=PExposure - No sign of trauma17
23 The monitor shows the following rhythm. What are your treatment priorities for this patient?
25 Color, CRT and pulse quality improves. Patient’s heart rate improved to 70 beats/min with assisted ventilation.Color, CRT and pulse quality improves.After BVM, patient’s RR increases to 20 breaths/min, good chest riseRapid glucose check 100 mg/dL20
26 12-month-old child You arrive at the house of a 12-month-old child. Mother states the child has a history of congenital heart disease and has been fussy for the last 3 hours.Mother states the child weighs 22 pounds.
27 12-month-old child Work of Breathing Appearance Circulation to Skin Mild retractionsAppearanceAlert but agitatedCirculation to SkinLips and nailbeds blue
28 On initial assessment, you note clear breath sounds, a RR of 60 breaths/min and a heart rate that is too rapid to count.What rhythm does the monitor show?
29 How can you distinguish SVT from sinus tachycardia?
30 SVT versus Sinus Tachycardia SVT (Supraventricular Tachycardia)Sinus Tachycardia• Vague history of irritability, poor feeding• History of fever, vomiting/diarrhea, hemorrhage• Cardiac monitor: QRS complex narrow; R to R interval regular; no visible P waves• Cardiac monitor: QRS complex narrow; R to R interval varies; P waves present and upright• HR > 220 beats/min• HR < 220 beats/min
31 Treatment Priorities Supplemental oxygen Obtain IV access Convert rhythm based on hemodynamic stabilityStable: vagal maneuvers or adenosineUnstable:IV /IO access obtained - adenosineNo IV/IO and unconscious - synchronized cardioversion
32 Blow-by oxygen administered IV startedAdenosine 0.1 mg/kg (1mg), given rapid IVP with 5 ml saline flushFive seconds of bradyasystole, followed by conversion to NSR
33 ConclusionCardiovascular compromise in children is often related to respiratory failure, hypovolemia, poisoning or sepsis.Management priorities for shock include airway management, oxygen and fluid resuscitation.Treat rhythm disturbances emergently only if signs of respiratory failure or shock are present.34