1. Emergency Room Management of Shock Dr Nishant Verma Assistant Professor Department of Pediatrics, KGMU © Nishant Verma

2. Mortality rates increase according to the degree of hemodynamic abnormality at presentation to the community hospital. Carcillo JA et al. Mortality and Functional Morbidity After Use of PALS/APLS by Community Physicians. Pediatrics 2009;124;500 N = 4856 2

3. Carcillo JA et al. Mortality and Functional Morbidity After Use of PALS/APLS by Community Physicians. Pediatrics 2009;124;500 Early reversal of any hemodynamic abnormality in the community hospital was associated with improved outcome. 3

4. A case scenario A previously healthy 12yr boy complains of severe malaise and shortness of breath. He describes onset of fever, pustular skin lesions and left knee swelling 2 days prior to his arrival in ER. O/E, he is alert but clearly ill and severely tachycardic (HR 160bpm). He has brisk capillary refill, bounding pulses and a BP of 100/36 mmHg. He receives 250ml NS over 1hr and is then transferred to PICU. On arrival he is noted to be obtunded, with extremely poor perfusion and undetectable BP. He is resuscitated with great difficulty and survives, albeit with renal insufficiency. Define Shock Types of Shock Stages of Shock Assessment of Shock Early Goal-directed management 4

5. What is shock ? Oxygen Delivery Oxygen Demand Oxygen Delivery = Arterial O2 content (CaO2) x Cardiac output (CO) CaO2 = (Hb x 1.34 x SaO2) + (0.003 x PaO2) CO = HR x Stroke volume Stroke volume : Function of Preload, Afterload & Myocardial Contractility 5

6. Stages of shock Initial Insult Triggers shock Decreased perfusion Body’s compensatory mechanism Compensated shockDecompensated shock Tissue damage Multisystem organ failure Death 6© Nishant Verma

7. Types of shock Hypovolemic Shock Distributive Shock Cardiogenic Shock Obstructive Shock Septic Shock 7© Nishant Verma

8. Warm Warm shock TachycardiaFlushed Brisk capillary refill Bounding pulses Wide pulse pressure Cold shock TachycardiaMottled Delayed refill Thready pulses Narrow pulse pressure Hypotension Cold + Prognosis -+ Cardiac Output - + Cardiac Output - Stages of Septic shock 8© Nishant Verma

9. Assessment of a child in shock

10. ABCD for any sick child in ER Airway Breathing Circulation Disability / Dextrose Not able to maintain airway Not breathing GCS < 8 INTUBATE 10© Nishant Verma

11. Hemodynamic assessment GOALS Identify Shock Identify the type of shock Identify the stage of shock Monitor treatment response 11© Nishant Verma

12. Assessment Vitals HR, RR, Pulse vol, BP Color, CFT, Core-periphery temp diff Pulse oximetry Continuous ECG Adequacy of organ perfusion Urine output Mental status Arterial Lactate Signs of overload Gallop rhythm Hepatomegaly Rales on auscultation Focused history Signs of dehydration Mucosa, eyes, skin turgor. 12© Nishant Verma

13. Hypotension: a word of caution ! Never wait for hypotension to set in Late sign in pediatric shock Indicates decompensated state Act as soon as you notice – Tachycardia / Impaired perfusion 13© Nishant Verma

14. Management of Shock

15. Crit Care Med 2009; 37:666–688 15

16. Emergency Room Management

17. Normal mental status Normal Peripheral perfusion (CFT < 3 s) Palpable distal pulses Normal blood pressure for age Urine output > 1ml/kg/hr Threshold HR GOALS 17 © Nishant Verma

18. Identify shock Begin oxygen Establish vascular access – IV – IO – Secure 2 lines STEP 1 0 - 5min FLUID BOLUS INOTRPOES Intra Osseous 18© Nishant Verma

19. Fluid resuscitation – Fluid type – Crystalloids vs Colloids – Amount – 20ml/kg boluses, push over 5-10 min Cautious in cardiogenic shock, newborns – How much to give ? Assess response after each bolus Watch for signs of overload Usually 40-60ml/kg STEP 2 5-15min Crystalloid NS/RL 20ml/kg5-10min Assess response Watch for overload 19© Nishant Verma

20. Correct hypoglycemia Correct hypocalcemia Begin Antibiotics for suspected septic shock If 2 nd IV line available – Consider inotrope STEP 2 5-15min Shock not reversed Fluid Refractory Shock 20 © Nishant Verma

21. Fluid Refractory Shock Obtain central access (ketamine) Start central inotrope STEP 3 15-60min Cold shock Dopamine (5-20 mcg/kg/min) Adrenaline (0.05-1 mcg/kg/min) Warm shock Norepinephrine (0.05-1 mcg/kg/min) Shock not reversed Catecholamine resistant Shock 21

22. Catecholamine resistant shock Consider Hydrocortisone – Indications – Dose – 50mg/m 2 /day to 50 mg/kg/day Transfer to PICU STEP 3 15-60min Fluid-refractory, catecholamine-resistant shock and suspected or proven adrenal insufficiency Stress dose Shock dose 22© Nishant Verma

23. Recognition, oxygen, access Hydrocortisone if at risk for adrenal insufficiency Rapid fluid boluses, glucose, antibiotics Additional IV/intraosseous access Secure airway, central access Begin to titrate vasoactive agent Titrate fluid resuscitation, inotropes with serial exams, supportive care until transport to PICU 5 15 First Hour Golden Hour of Shock Management 23© Nishant Verma

24. PICU Management

25. CFT ≤2 s Normal BP Normal peripheral and central pulses Warm extremities Urine output > 1 mL/kg/hr, Normal mental status ScvO2 saturation > 70% Cardiac index - 3.3 - 6.0 L/min/m 2 Therapeutic end points 25© Nishant Verma

26. Establish arterial line Monitor CVP – Attain normal MAP – CVP Monitor ScvO2 – Target > 70% Consider Mechanical ventilation PICU management Term NB – 55 mmHg Upto 1yr – 60 mmHg 2-15yr - 65 mmHg 26© Nishant Verma

27. Inotropic and Vasoactive drugs DrugInotropyVasoconstrictionVasodilation Dopamine+++ (β1) (5-10mcg/kg/min) ++ (ɑ) (>10mcg/kg/min) - (D) (<2mcg/kg/min) Dobutamine+++ (β1) -++ (β2) Adrenaline++++++ Noradrenaline-+++- Vasopressin-+++- NTG/NTP--+++ Milrinone+++-++ Enoximone+++-+ Levosimendan+++-+ INOTROPES VASOPRESSORS VASODILATOR INODILATORS 27© Nishant Verma

28. PICU management Catecholamine resistant Shock Cold shock with Normal BP Cold shock with Low BP Warm shock with Low BP Maintain Hb > 10 Titrate fluid and epinephrine Consider vasodilators (NTG, Milrinone, Levosimendan) Titrate fluid and epinephrine If still hypotensive, consider norepi Consider inodilators Titrate fluid and norepinephrine If still hypotensive, consider vasopressin Consider low dose adre 28 © Nishant Verma

29. PICU management Shock not reversed Refractory shock: ECMO 29© Nishant Verma

30. Supportive care Blood products Glycemic control Diuretics and renal replacement 30© Nishant Verma

31. Questions 31© Nishant Verma

32. Case scenarios

33. A 2-year-old previously healthy boy develops profuse diarrhea, vomiting, and lethargy Heart rate 176/min, blood pressure 78/60 mm Hg, respiratory rate 40/min, temperature 96.7°F, Sp O 2 98% Child arouses to needle sticks, is extremely mottled, and has thready pulses Clear lungs and precordium, abdomen is scaphoid and non- tender What is your impression? What is your initial management? Case 1 33 © Nishant Verma

34. Hypovolemic Shock Start high flow oxygen Achieve prompt IV or intraosseous access Provide rapid bolus with isotonic crystalloid Correct hypoglycemia if present Provide additional fluid boluses as indicated, consider possible ongoing losses Case 1 34© Nishant Verma

35. – A 3-week-old infant is evaluated for lethargy, poor feeding, rapidly worsening appearance, and evolving respiratory distress – Heart rate 190/min, blood pressure 60/46 mm Hg, respiratory rate 70/min, SpO 2 95%, temperature 38.0°C (100.3°F) – Mottled, thready upper extremity pulses, and cold lower extremities – Lung fields have crackles and liver is enlarged – Bedside glucose is 90 mg/dL, arterial blood gas shows a pH of 7.16 with a pCO 2 of 20 mm Hg. Ionized calcium is normal What type of shock is this? What is your management plan? Case 2 35© Nishant Verma

36. Cardiogenic Shock Due to Ductal-Dependent Lesion ABCs with urgent vascular access Evaluate response to small (5-10 mL/kg) fluid boluses Begin prostaglandin infusion (0.05 mcg/kg/min) until echocardiogram excludes duct-dependent congenital heart disease Support circulation with volume, inotropes as required Urgent consultation with a cardiologist Case 2 36© Nishant Verma

37. – A 12-year-old 25kg inpatient with flu and knee pain collapses in his room. You are called to evaluate him in the pediatric ward – Heart rate 168/min, respiratory rate 56/min, temperature 94.9°F, – BP 70/30 mm Hg, Sp O 2 96% on non-rebreather face mask – Barely responsive to painful stimuli – Skin mottled, distal pulses are imperceptible – Lungs are clear, without retractions – Unremarkable precordium and abdomen – Left knee is obviously inflamed – No urine output What is your diagnosis? What is your plan of management ? Child receives 500ml NS over 30min. Is it appropriate ? Transferred to PICU. After receiving 1000ml NS over 15min, develops hepatomegaly and rales, still hypotensive, CFT>3, mottled. What next ? Start Dopa Secure central access, measure CVP Still in shock, what next ? Start Adrenaline Case 3 37 © Nishant Verma

38. – A 16-month-old with cough presents in progressive respiratory and cardiovascular failure – The child is sedated, intubated, and ventilated. Heart rate 200/min, blood pressure 82/66 mm Hg, respiratory rate 32/min, temperature 37°C (98.5°F), Sp O 2 100% on 80% oxygen – Skin is mottled, poor distal pulses – Breath sounds are diminished on the right – The abdomen is unremarkable What additional study would you consider? What is your management plan? Case 4 38

39. Obstructive Shock Needle aspiration with eventual chest tube placement Fluid bolus administered (10-20 mL/kg of IV normal saline or lactated Ringer’s) Use caution with medications with the potential for vasodilation – Morphine – Propofol – Benzodiazepines Case 4 39© Nishant Verma

40. Key Points Rapid recognition of shock is essential to good outcomes Don’t wait for Hypotension to set in Initiate management of ABCs with particular attention to rapid fluid resuscitation, early antibiotics, and consider prostaglandin E in neonates More conservative with fluids in cardiogenic shock (5-10 mL/kg aliquots) Management should be directed at normalizing tissue perfusion and blood pressure (Goal directed) Frequent/Continuous monitoring as appropriate If patient is not responding the way you think broaden your differential, think about other types of shock 40© Nishant Verma

41. “You may delay, but time will not.” Benjamin Franklin

42. Thank You