Hypoperfusion and Shock Welcome. This lesson on hypoperfusion and shock is part of the NAEMT Emergency Pediatric Care Course.

Hypoperfusion Common problem Extent makes resuscitation difficult Shock due to hypoperfusion Start fluid resuscitation as soon as possible Hypoperfusion is a common problem in the pediatric population. The extent of the shock can make resuscitation difficult. This child is in shock due to hypoperfusion. Fluid resuscitation should be started as soon as possible.

Overview Describe differences between compensated and uncompensated shock Review differences of distributive, non-distributive and obstructive shock Explore pathophysiology for different etiologies of shock Discuss interventions for early and late shock This lesson will discuss how children in shock or a hypoperfusion state present differently than an adult. It will also: Describe the differences between compensated and uncompensated shock. Review the differences between various categories of shock including distributive, non-distributive and obstructive. Explore the variable pathophysiology for different etiologies of shock. And discuss interventions for early and late shock.

Physiology BP = Cardiac Output x Systemic Resistance Cardiac Output = Stroke Volume x Heart Rate After-load = Resistance to blood being ejected Pre-load = Blood returned to heart Starling’s Law = Amount of cardiac muscle stretch A review of physiology is needed to help understand how children respond to shock. Blood pressure is a measurement of cardiac output times systemic resistance. Cardiac output is determined by multiplying stroke volume – the amount of blood ejected from the heart with each beat – by the heart rate. The amount of blood ejected from the heart during contraction is determined by: the amount of blood returned to the heart – which is called pre-load, the amount of stretch the cardiac muscles have – which is Starling’s law, and the amount of resistance to the blood being ejected from the heart by the vessels it will enter – which is called after-load. LifeART NHTSA

Shock Compensation Children vs. Adults Increased heart rate Vasoconstriction Prolonged compensation Rapid decompensation Adults Increased stroke volume Vasoconstriction Tachycardia Slow, but sustained compensation The body attempts to keep oxygen perfusion and circulation to its vital areas. Children will compensate differently than adults in an attempt to maintain this perfusion. Children first become tachycardic and then their blood vessels vasoconstrict. This massive vasoconstriction is the predominate compensatory mechanism for children. Due to intact compensatory mechanisms, children will compensate for a longer period of time than adults, but their decompensation will be rapid. By contrast, adults initially increase stroke volume, then vasoconstrict, and finally become tachycardic. Thus adults have a slow but sustained compensation response until decompensation. Adult’s compensatory mechanisms are often impaired by a history of cardiac problems. EPS411.com

Categories of Shock Non-Distributive Hypovolemic Hemorrhagic Metabolic Categories of shock include non-distributive shock due to hypovolemia either due to hemorrhage or metabolic losses such as vomiting and diarrhea.

Categories of Shock Distributive Anaphylaxis Septic Neurogenic Distributive shock includes: Anaphylactic shock – systemic response from an allergic reaction Septic – profound reaction to sepsis with a systemic vasodilatation Neurogenic – involving a disruption of the sympathetic response of the body resulting in vasodilatation below the injury site

Categories of Shock Obstructive Pulmonary embolus Tension pneumothorax Cardiac tamponade Obstructive shock includes: Pulmonary emboli Tension pneumothorax – due to impaired cardiac output, requires needle decompression and chest tube placement Cardiac tamponade due to the collection of fluid in the peicardial sac, limiting the stroke volume ejected from the heart, requires cardiocentesis

Etiologies of Hypoperfusion (Common) Emesis and diarrhea Osmotic diuresis from diabetes Internal or external blood loss Plasma loss from sepsis or anaphylaxis These are common causes of shock in pediatric patients due to a decrease in circulating blood volume. Hypovolemia will initially require fluid resuscitation to correct losses and restore perfusion.

Etiologies of Hypoperfusion (Uncommon) Spinal cord injury Cardiac failure Spinal cord injury and cardiac failure are uncommon causes of shock. A good assessment and a high index of suspicion are required to determine that spinal cord injury or cardiogenic shock is the cause of the hypoperfusion. Fluid boluses may be given initially depending upon how the patient presents, but usually these types of shock require presser medications to restore perfusion and oxygenation to the tissue. Medications required to restore perfusion

Severity of Hypoperfusion Compensated Decompensated Signs are due to inadequate tissue perfusion Volume Signs of compensated shock in children are due to inadequate tissue perfusion that initiates the body’s compensatory mechanisms in an attempt to maintain perfusion and blood pressure. If shock is identified in this stage, it is often reversible with aggressive fluid therapy. Compensated shock is reversible with fluids Time

Severity of Hypoperfusion Compensated Shock Signs Decompensated Volume Pulse Breathing Blood Pressure Signs of compensated shock are due to a sympathetic response. There is an initial increase in respiratory rate to increase oxygenation to the tissues. The heart rate increases and there is a delay in capillary refill – but remember, a cold environment also can cause a delay in capillary refill. Peripheral pulses become weak and the extremities become cool. If a blood pressure is obtained, it will be normal during the compensated stage. One of the first changes noted will be a change in mental status, with an awake patient becoming irritable and/or anxious. AVPU Altered Mental Status Time

Severity of Hypoperfusion Compensated Shock Signs Decompensated Decompensated Weak or absent peripheral pulses, weak central pulses Volume Weak peripheral pulses, strong central pulses A quick way to determine if the pediatric shock patient is in compensated versus decompensated shock is by assessing pulses. Peripheral pulses and central pulses should be checked at the same time in order to compare strength. Weak peripheral pulses but strong central pulses equals compensated shock. Weak peripheral pulses or absent peripheral pulses and weak central pulses equals decompensated shock. Time EPS411.com

Severity of Hypoperfusion Dehydration Testing This is an image of dehydration testing that involves pulling on and releasing a child’s skin. A normovolemic patient’s skin will quickly return to normal after being released. A hypovolemic patient’s skin will “tent” or remain in the folded position after it is released, as shown in image two. Hypovolemic patient’s skin will “tent”

Severity of Hypoperfusion Decompensated Shock Inadequate tissue perfusion to all organs Volume Decompensated shock results from the body’s inability to continue to compensate for the continued shock state. The result is inadequate tissue perfusion to all organs including the vital organs – such as the heart, lungs, liver and kidneys – that were initially protected by compensatory mechanisms. Body is unable to continue compensation Time

Severity of Hypoperfusion Decompensated Shock Signs Volume Pulse Breathing Blood Pressure Signs of decompensated shock show the changes the body experiences as it progresses toward death. If the shock state is not reversed, death is the end product. The patient’s level of consciousness progresses to lethargy, responsive to verbal stimulus, then pain stimulus, unresponsive, and then to death. Tachycardia increases and then progresses to bradycardia. Tachypnea increases and becomes bradypnea. Pulses become weak or absent both peripherally and centrally. Capillary refill becomes markedly delayed or absent. Extremities become cool, pale or mottled. Finally there is a downward change in blood pressure called hypotension. AVPU V P U Altered Mental Status Weak or absent peripheral pulses, weak central pulses Time

Severity of Hypoperfusion Decompensated Shock Signs This is an image of a decompensated toddler. Some signs of decompensated shock seen in this image include: Decreased level of consciousness and pale, cool or mottled extremities. Health care providers are shown taking aggressive measures to restore perfusion to vital organs.

Assessment Assessment begins with a scene survey and forming a general impression of the child using the pediatric assessment triangle.

Hazards to you, your partner, the patient and bystanders Scene Survey The Scene Survey is the first part of every call. Look for hazards to you, your partner, the patient and bystanders. Hazards to you, your partner, the patient and bystanders

First Impression Pediatric Assessment Triangle Compensated or decompensated The first impression using the pediatric assessment triangle is made while approaching the child. Decompensated children will appear ill while compensated children will have more subtle signs and symptoms. EPS411.com

First Impression General Appearance Observe interactions Not sick - attentive to environment, focus on familiar people and objects, alert for threats Good brain function requires adequate oxygenation, ventilation, cerebral perfusion Sick - does not care you are present or recognize parents The general appearance will tell you whether the child’s physiology is compensated or not. In other words, it tells you if the child is “sick” or “not sick.” Assessing a child’s general appearance mostly involves observing their interactions with the environment. A normal healthy child is attentive to their environment, focusing on familiar people and interesting objects and alert for possible threats. Good brain function requires adequate oxygenation, ventilation, cerebral perfusion and healthy brain tissue. If the child’s interaction with the environment is good, the body is still compensating for the illness or injury well enough to oxygenate, ventilate and perfuse the brain. If the child does not care that you are present or does not recognize its parents, you should be concerned that the child is decompensated.

First Impression General Appearance Muscle tone Spontaneous movements Skin color Other signs of distress General appearance also includes a quick survey of the child’s muscle tone and spontaneous movements, the overall color of their skin and mucus membranes, and other signs of distress such as abnormal positions of comfort. A child who’s limp and not moving, who is pale or has cyanosis, or who is maintaining a tripod or other abnormal position is probably sick. KyleDavidBates.com

First Impression Work of Breathing The work of breathing side of the triangle looks at and helps the PAT provide specificity because it can tell you if respiratory function is also a problem.

Skin color, capillary refill, distal vs. central pulses First Impression Circulation to the Skin The Circulation to the Skin side of the PAT also lends the tool “specificity” because it tells us if one of the main physiologic malfunctions is in the circulatory system. One of the earliest compensatory mechanisms for decreased circulation is peripheral vascular constriction, as reflected by skin color and temperature, capillary refill and distal versus central pulse quality. Skin color, capillary refill, distal vs. central pulses

First Impression Sick Not Sick Rapid Initial Assessment Significant MOI? Rapid Initial Assessment Yes No Appropriate Interventions Relationship Use the first impression findings to determine “How sick” and “How quick?” Transport Priority Involve Family Transport Method Detailed History Transport Destination Focused Physical Exam

Initial Assessment Airway Loss of airway may occur in decompensated shock The purpose of the initial assessment is to identify and immediately treat life threats. Remember that as level of consciousness changes – which is driven by brain perfusion – the ability to protect the airway is diminished. Airway protection may be required for pediatric shock patients. Identify and treat life threats

Initial Assessment Breathing Assess for chest trauma Abnormal sounds Rate effort and volume To ensure adequate oxygenation and ventilation, breathing needs to be fully assessed during the initial assessment. Look at the child’s breathing rate, effort and tidal volume. Listen for abnormal breath sounds. Remember that chest trauma can cause shock – so assess for a tension pneumothorax and for cardiac tamponade if there is a possible mechanism. Treat hypoxia with high flow oxygen and treat any identified causes of respiratory distress with the tools and training you have. Administer O2 and treat cause

Initial Assessment Circulation Compensated Weak peripheral pulses, strong central pulses Assessment of circulation includes the comparison of central versus peripheral pulses. The quality of these pulses will indicate whether the child is in compensated or decompensated shock. Weak peripheral pulses but strong central pulses equals compensated shock. Weak peripheral pulses or absent peripheral pulses and weak central pulses equals decompensated shock. Capillary refill is an indicator of tissue perfusion and should be assessed, but it may not be accurate in a cold environment or in specific patient. During a rapid head-to-toe exam, look for signs of internal bleeding and external hemorrhage or bleeding. Immediately apply pressure to severe external bleeding. Decompensated Weak or absent peripheral pulses, weak central pulses EPS411.com EPS411.com

Initial Assessment Circulation Management – Intravenous Fluid bolus if any signs of shock Early recognition of hypoperfusion and fluid resuscitation are key Select a large bore catheter Location close to central circulation Two IVs may be needed IV access is only indicated if the child presents with any signs of shock. If there are subtle changes in vital signs such as tachycardia and tachypnea and a high index of suspicion of shock, a fluid bolus should be given and the patient should be reassessed for shock. Early recognition of hypoperfusion and fluid resuscitation are the key to preventing compensated shock from progressing to decompensated shock. For an IV, select a large bore catheter and a location close to central circulation. Two IVs may be needed to adequately fluid resuscitate the child.

Initial Assessment Circulation Management – Intraosseous An IO can be used in any age child – even if they are awake. An IO is easy to use and can rapidly achieve vascular access with a high success rate. Can be used on any age child

Intraosseous Space Blood Flow The intraosseous space is a specialized area of the vascular system that is often referred to as a non-collapsible vein. Blood flow is steady and generally continues even in shock. Pressure in the IO space – which can be monitored with a pressure transducer – is approximately one-third of systemic pressure. We can withdraw bone marrow from the IO space but generally cannot deposit anything permanently into the marrow because it gets washed out with the blood flow. During IO infusions, we deliver fluid and medication into the vascular system through the intraosseous space, thus the term “IO Vascular Access.”

Anatomy Neonate Leg Cross Section Skin Subcutaneous Fat Intraosseous Catheter Tibia Fibula Posterior Compartment Anterior Lateral You can also see the various compartments that can be compressed or filled should fluid be inadvertently infused in the incorrect area. This leakage – or extravasation – can lead to compartment syndrome.

Other Issues IO Insertion Depth based on patient size and weight Gently insert catheter Advance catheter slowly Feel needle drop into medullary space Frequently monitor insertion site and extremity Need hands-on training The decrease in circulation to a distal area secondary to compartment syndrome may cause significant injury. For this reason it is imperative to: Plan placement depth based upon patient size and weight. Gently insert the catheter – do not use excessive force or speed. Advance the catheter slowly – allow the driver to do the work. Feel the needle set tip drop into the medullary space – stop when you feel the pop. Frequently monitor the insertion site and extremity for the signs and symptoms of extravasation or compartment syndrome. Gently and slowly advance the catheter to place the IO needle tip into the medullary space. Use control and precision to avoid serious complications! Do not attempt IO insertion without proper hands-on training from a qualified instructor using appropriate training equipment and simulators.

IO Insertion Anatomical Landmarks Patella Tibial Tuberosity Three important anatomical landmarks for IO insertion are visible in this image: the patella, the flat aspect of the medial tibia, and the tibial tuberosity – if present. Remember that the tibial tuberosity is not prominent in infants and young children. Medial Tibia

IO Insertion Unable to Palpate Tibial Tuberosity Here is something important to remember: The tibial tuberosity is often difficult or impossible to palpate on very young patients! The IO insertion site for small patients – where the tibial tuberosity cannot be palpated – is “two finger widths below the patella and then medial along the flat aspect of the tibia.” Finger Width Finger Width Often difficult or impossible to palpate

IO Insertion Able to Palpate Tibial Tuberoisty The IO insertion site for more mature patients – where the tuberosity can be palpated – is “one finger width distal to the tibial tuberosity along the flat aspect of the medial tibia.” Finger Width

Anatomy Neonate Leg Cross Section Traditional IO Catheter Tibia Fibula Initiating an IO in a neonate is significantly different than placing one in a school-aged child. Note the small intraosseous space, the thin bone density, and the lack of a tibial tuberosity lateral to the insertion site. Now let’s compare the density of relatively small patient weighing approximately 2 kg to that of a much larger patient weighing approximately 35 kg. Left Leg

Anatomy 11 y.o. Tibia Cross Section Insertion Site Tibia Fibula In the school-aged child, it is easy to appreciate the tibial tuberosity. Also note the larger intraosseous space, the thicker bone density and the tuberosity lateral to the insertion site. Left Leg

Pain Somatic and Visceral It is important to discuss pain as it relates to IO usage. Preconceived or misinformed viewpoints can lead to inappropriate use and possible complications. There are two types of pain to consider with IO insertion – somatic and visceral. Somatic pain is the pain you feel on the surface of your body while visceral pain is the pain you feel internally.

Initial Assessment Circulation Management – Crystalloids A fluid bolus is required to increase perfusion in the pediatric shock patient. Crystalloids – like normal saline or lactated ringers – are the fluid of choice, but follow your protocols on which fluid to use. Administer 20ml/kg of fluid rapidly – in less than 20 minutes. After each bolus, reassess circulation – central and peripheral pulses, capillary refill and skin parameters – to evaluate the need for additional boluses. Most pediatric shock protocols will allow up to three fluid boluses to be given prehospitally. 20 mL/kg, < 20 minutes Reassess patient after each fluid bolus

Initial Assessment Never Administer D5W D5W never should be used for fluid boluses because every 100 milliliters of D5W contains 5 grams of dextrose. Utilizing D5W can lead to hyperglycemia. D5W can lead to hyperglycemia

Initial Assessment Circulation Management – Medications Sepsis Pressers and antibiotics Cardiogenic Shock Pressers, furosemide, morphine and antiarrhythmics Hypoperfusion in children rarely requires medications for treatment. Nonetheless, the medications that might be administered for several types of shock include: Pressers and antibiotics for sepsis. Pressers, lasix, morphine and antiarrhythmics for cardiogenic shock. Epinephrine, Benadryl and Solu-Medrol for treatment of anaphylaxis. Anaphylaxis Epinephrine, diphenhydramine, Solu-Medrol EPS411.com

Initial Assessment Circulation Management – Medications If medications are given to treat hypoperfusion, it is after fluid boluses have been given with little result. Either epinephrine or dopamine are given to cause vasoconstriction and to improve stroke volume. Use medications after fluid boluses EPS411.com

Rapid transport for pediatric shock patients Transport Decision The final step of the initial assessment is making a transport decision. Patients presenting with either compensated or decompensated shock need to be transported rapidly for emergency department evaluation and to continue treatment therapies. Complete further patient assessment and additional therapies en route to the receiving facility. Rapid transport for pediatric shock patients

Focused History Questions to Determine Type of Shock Bleeding Vomiting Diarrhea Fluid intake / urine output As time allows, ask specific focused history questions to help determine the type of shock the patient is experiencing. To determine if the shock is hypovolemic, ask history questions about bleeding, vomiting, diarrhea and if the child is urinating or drinking normally. Check for a fever if you suspect sepsis. Signs of anaphylaxis include bites, stings, hives and swelling, and facial, lip and mouth swelling. Fever Anaphylaxis signs FEMA Photo Library / Andrea Boomer

Head to Toe Physical Exam Done En Route The head-to-toe physical exam should be done en route to the hospital on all patients showing signs of shock.

Ongoing Assessment Done Frequently Reassessment should be done frequently and after every fluid bolus.

Summary Recognition and rapid intervention are keys to treatment Pulse quality and level of consciousness are key indicators Obtain IV or IO access if shock treatment is needed Deliver crystalloid fluids at 20 mL/kg In summary, prehospital providers need to have a high index of suspicion of shock due to history and mechanism of injury. Early recognition and rapid interventions are the key in treating shock and preventing the patient from becoming decompensated. Assessment of pulse quality and level of consciousness are key indicators of shock. Only obtain IV or IO access if shock treatment is needed. Deliver crystalloid fluids for fluid resuscitation at a rate of 20 milliliters per kilogram.