Shock, Multiple Organ Dysfunction Syndrome, and Burns in Children Chapter 47 Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

2 Shock and Multiple Organ Dysfunction Syndrome (MODS) Shock Shock Commonly results from hemorrhage, severe dehydration, progressive heart failure, or sepsis Commonly results from hemorrhage, severe dehydration, progressive heart failure, or sepsis Compensated shock Compensated shock Decompensated shock Decompensated shock

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Shock Hypovolemic shock Hypovolemic shock Distributive or vasogenic shock Distributive or vasogenic shock Neurogenic shock Neurogenic shock Cardiogenic shock Cardiogenic shock Septic shock Septic shock

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 4Shock Dehydration, hypovolemia, low cardiac output stimulate adrenergic and renal compensation Dehydration, hypovolemia, low cardiac output stimulate adrenergic and renal compensation Tachycardia Tachycardia Redistribution of blood from the skin, gut, and kidney to the brain and heart Redistribution of blood from the skin, gut, and kidney to the brain and heart Reduced renal perfusion stimulates the renin- angiotensin-aldosterone system, resulting in renal sodium and water retention Reduced renal perfusion stimulates the renin- angiotensin-aldosterone system, resulting in renal sodium and water retention Neonatal and young infant kidneys are incapable of excreting concentrated urine Neonatal and young infant kidneys are incapable of excreting concentrated urine Compensatory mechanisms are relatively ineffective during the first weeks of life Compensatory mechanisms are relatively ineffective during the first weeks of life

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Reperfusion Injury Cellular damage caused by the restoration and reperfusion of oxygen to cells that have been exposed to reversible hypoxic conditions Cellular damage caused by the restoration and reperfusion of oxygen to cells that have been exposed to reversible hypoxic conditions Occurs from the generation of highly reactive oxygen intermediates Occurs from the generation of highly reactive oxygen intermediates The amount of free oxygen radical production depends on the severity and duration of the ischemic period The amount of free oxygen radical production depends on the severity and duration of the ischemic period

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Evaluation of Shock Arterial blood gas (ABG) Arterial blood gas (ABG) Serum lactate concentration Serum lactate concentration Blood pressure Blood pressure Ventilation and oxygenation Ventilation and oxygenation Chemistry analytes Chemistry analytes Electrolytes, glucose, BUN, liver function, calcium, phosphorus, cardiac enzymes Electrolytes, glucose, BUN, liver function, calcium, phosphorus, cardiac enzymes Hemoglobin and hematocrit Hemoglobin and hematocrit

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Treatment of Shock Adequate oxygen delivery Adequate oxygen delivery Monitor body temperature Monitor body temperature Transfusion of blood components Transfusion of blood components IV fluids (volume resuscitation) IV fluids (volume resuscitation) Monitor urine output and specific gravity Monitor urine output and specific gravity Monitor blood pressure Monitor blood pressure

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Emerging Therapies for Shock and Sepsis Injury prevention Injury prevention Haemophilus influenzae and Neisseria meningitidis vaccines Haemophilus influenzae and Neisseria meningitidis vaccines Colony-stimulating factors to increase white blood counts in immunocompromised individuals Colony-stimulating factors to increase white blood counts in immunocompromised individuals Infectious disease control Infectious disease control Resuscitation techniques Resuscitation techniques

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Emerging Therapies for Shock and Sepsis Mediator-specific therapies Mediator-specific therapies Continuous plasma filtration Continuous plasma filtration Glucocorticoid administration Glucocorticoid administration Activation of Toll-like receptors Activation of Toll-like receptors Genetic profiling Genetic profiling

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Multiple Organ Dysfunction Syndrome (MODS) Failure of at least two organs that results from a single cause Failure of at least two organs that results from a single cause Risk factors: sepsis, trauma, cardiopulmonary arrest, congenital heart disease, liver/bone marrow transplantation Risk factors: sepsis, trauma, cardiopulmonary arrest, congenital heart disease, liver/bone marrow transplantation Children with chronic diseases have an increased risk and increased mortality Children with chronic diseases have an increased risk and increased mortality

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Burns A common result of inadequate supervision, curiosity, inability to escape the burning agent, or intentional abuse A common result of inadequate supervision, curiosity, inability to escape the burning agent, or intentional abuse Child abuse Child abuse 6% to 20% of child burn injuries are child abuse 6% to 20% of child burn injuries are child abuse Pattern burns, forced emersion burns, splash/spill burns, cigarette burns Pattern burns, forced emersion burns, splash/spill burns, cigarette burns

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Burns Scald injuries Scald injuries Contact burns Contact burns Flame burns Flame burns Electrical burns Electrical burns Chemical burns Chemical burns

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Severity of Injury Total body surface area (TBSA) Total body surface area (TBSA) Rule of nines inaccurate in children Rule of nines inaccurate in children Arms and trunk demonstrate same proportions as an adult Arms and trunk demonstrate same proportions as an adult Head and neck18% Head and neck18% Each lower extremity14% Each lower extremity14% Depth of injury Depth of injury Infant skin is extremely fragile and more likely to sustain a deeper burn Infant skin is extremely fragile and more likely to sustain a deeper burn

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Severity of Injury Age Age Younger than 2 years, a significantly higher risk for associated morbidity and mortality Younger than 2 years, a significantly higher risk for associated morbidity and mortality Have not achieved maturity of immune system and are at increased risk for infection and sepsis Have not achieved maturity of immune system and are at increased risk for infection and sepsis Very young children are intolerant of rapid fluid shifts; immature renal function negatively affects ability to retain sodium and water Very young children are intolerant of rapid fluid shifts; immature renal function negatively affects ability to retain sodium and water Areas of the body burned Areas of the body burned Secondary injuries and manifestations Secondary injuries and manifestations

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Burn Injury in Children Integumentary system Integumentary system Cardiovascular system Cardiovascular system Renal system Renal system Gastrointestinal system Gastrointestinal system Metabolism Metabolism

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Burn Injury in Children Immune function Immune function Scar maturation Scar maturation Burn shock Burn shock Pulmonary system Pulmonary system Infection Infection

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Burn Injury in Children Functional limitations Functional limitations Fluid resuscitation Fluid resuscitation Wound management Wound management Pulmonary support Pulmonary support Nutritional support Nutritional support

Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Burn Injury in Children Comfort management Comfort management Community reintegration Community reintegration