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Pediatric shock :open_mouth: (:heartpulse: Basic Hemodynamic (Mixed or…
Pediatric shock :open_mouth:
:green_heart:
Definition
Acute process
characterized by
body's
inability to deliver adequate O2 to meet metabolic demands
of Vital organs and tissues
#
Compensation for
Inadequate O2 delivery
➯ attempt to
preserve Oxygenation of Vital organs
(Brain, Heart, Kidneys, Liver) at the
expense
of other organs (skin, GI tract, muscles)
:warning:
Untreated shock
➯
Irreversible
tissue and organ injury and death
:tada: Shock can exist
without hypotension
:earth_asia:
Epidemiology
occurs 2% of all hospitalized infants, children and adults in developed countries
most pt dies from result of asso. complications and
Multiple organ dysfunction syndrome (MODS)
:two_hearts:
Role of Cardiovascular system in O2 delivery
O2 Content
= O2 content of RBC :heavy_plus_sign: O2 dissolved in plasma
= (Hb x SatO2 x 1.34) :heavy_plus_sign: (PaO2 x 0.003)
Oxygen delivery (DO2)
= Cardiac output (CO) x Arterial O2 content (CaO2)
CO = HR x SV
SV determined by preload, afterload and contractility
CaO2 =
O2 content
Tissue hypoxia
Hypoxemia
hypoxia
Severe UAO
Cyanotic heart ds
Anemic
hypoxia
Acute blood loss
Acute hemolysis
Ischemic
hypoxia
Poor heart contractility
Severe dehydration
Histologic or Cytotoxic
hypoxia
Cyanide toxicity
:gear:
PathoPSO of shock
Microcirculatory dysfunc
Precapillary sm. ms. contraction ➯ :arrow_down:Capillary blood flow
Release of biochemical mediators
Vasoactive agents like LTs, PGs
Cytokines like TNF-alpha, IL
Complement activation
Tissue hypoxia
Revert to
anaerobic metabolism
➯ :arrow_down: energy (2 ATP) ➯ produce
lactate
➯ Metabolic acidosis
:shower:
Stages of Shock
Early or Compensated shock
#
Tachycardia (earliest sign)
Vital organ func maintained
BP remains normal
should
early detect and treat
Uncompensated or Hypotensive shock
#
Microvascular perfusion becomes marginal
Organ & cellular function deteriorate
Hypotension develops
Irreversible shock
Hypotension with
Bradycardia
:warning:
Warning signs
Marked tachycardia
Absent or Diminishing peripheral pulses
Weakening central pulses
Cold distal extremities with Prolonged capillary refill
Narrowing pulse pressure
Altered mental status
Hypotension (Late finding)
:gear:
Compensatory mechanisms
Baroreceptors
Chemoreceptors
RAAS
Humoral responses
Autotransfusion
:classical_building:
Classification of Shock
Hypovolemic shock
:star: M/C cause of shock in children
:arrow_down: circulatory volume
:arrow_down: preload
:arrow_down:SV ➯ :arrow_down: CO
:cat:
Etiology
Hemorrhage
Renal losses and/or GI fluid losses --
ท้องเสีย, อ้วกแตก
Capillary leak syndromes
:frame_with_picture:
Clinical
Hx of vomiting/diarrhea/trauma/blood loss
อย่าลืมถาม last void to evaluate dehydration
Signs of dehydration
Mild
(< 5% weight loss or 50 ml/kg)
Mild :arrow_up: thirst
Slight mucous mb dryness
Slight :arrow_down: in urinary freq
Slight :arrow_up: pulse rate
Moderate
(5-10% weight loss or 50-100 ml/kg)
Moderate :arrow_up: in thirst
Very dry,
'beefy red'
mucous mb
:arrow_down: skin turgor
Tachycardia
Oliguria, Concentrated urine
Sunken eyes
Severe
(10-15% weight loss or 100-150 ml/kg)
Severe thirst
Tenting of skin
No tears when crying
Weak, thready pulses
Marked tachycardia
Sunken fontanelle
Hypotension
Hypotension, Tachycardia w/o signs of CHF
Cardiogenic shock
:arrow_down: CO due to :arrow_down: contractility
Seen in pt with Congenital or Acquired heart ds
:memo:
Def
: includes
Hemodynamic parameters
as follows
Persistent hypotension
(SBP 80-90 mmHg or mAP 30 mmHg lower than baseline)
Severe reduction in Cardiac index
(1.8L/min/m2 without support
or
2.0 to 2.2 L/min/m2 with support)
Adequate or Elevated filling pressure
(eg. LV End-diastolic pressure 18 mmHg
or
RV end-diastolic pressure 10-15 mmHg)
:frame_with_picture:
Clinical
Sign of Pulmonary or Systemic venous congestion
Normal BP or Narrow pulse pressure
Clinical deterioration in Perfusion and Respiratory func in response to Fluid resuscitation
Obstructive shock
Any lesion
that creates a mechanical barrier/obstruction that impedes adequate CO
Seen in Pericardial tamponade, tension pneumothorax, pulmonary embolism, and ductus-dependent congenital heart lesions
:cat:
Etiologies
Massive PE
Tension pneumothorax
Cardiac tamponade
Ductal dependent for Systemic blood flow
Treat U/D cause
Distributive shock
Inadequate vasomotor tone ➯ capillary leak & maldistribution of fluid into interstitium
Pooling of blood in peripheral vasculature ➯ Blood flow back to heart :arrow_down: ➯ Hypotension
Inappropriate vasodilation, Endothelial dysfunc with capillary leak or Loss of vascular tone
Eg. Septic shock, Anaphylactic shock, Neurogenic shock
:star: M/C
secondary to sepsis
Anaphylactic
shock
Def:
Acute systemic
(multi-system) & very severe
Type 1 hypersensitivity
allergic reaction
Quick release of immunological mediators
-- Histamine, PGs, Leukotrienes
➯ leading to
systemic vasodilation
(asso. with sudden drop in BP)
&
edema of bronchial mucosa
(➯ Bronchoconstriction & difficulty breathing) fr mast cells
Neurogenic
shock
Def:
Severe CNS damage
(brain & SC)
Mech: Sudden loss of
Sympathetic stimulation
➯ Vss. suddenly relax ➯ Sudden :arrow_down: Peripheral vascular resistance (vasodilation) & :arrow_down: BP
Wide pulse pressure & Bradycardia
Septic shock
Synonyms with
Distributive shock
Septic process usu involves
more complex interaction of distributive, hypovolemic, and cardiogenic shock
Systemic Inflammatory Response Syndrome (SIRS)
Sepsis
= SIRS + proof of infection
:!:
Severe sepsis
= sepsis +
at least 1 of the following
Cardiovascular organ dysfunc
or
ARDS
or
Organ dysfunction
at least 2 organs
Def:
Sepsis with Cardiovascular dysfunc
Acute circulatory failure was characterized by
persistent arterial hypotension
after adequate volume resuscitation
unexplained by other cause
:kiwifruit: Neonatal shock
DDx
Congenital adrenal hyperplasia
Inborn errors of metabolism
Obstructive Lt sided cardiac lesions
Aortic stenosis
Hypoplastic left heart syndrome
Coarctation of aorta
Interrupted aortic arch
:male-scientist::skin-tone-5:
Laboratory & Monitoring
:grapes:
:heartpulse:
Basic Hemodynamic
O2 consumption = CI(cardiac index)
x
[Arterial O2 content
-
Venous O2 content]
CI = CO per BSA (body surface area)
O2 content = [(1.34 x Hb x SpO2) + PaO2 x 0.003)]
ScvO2 = SVC O2 sat or Mixed venous sat
:yellow_heart: O2 consumption = CI x [(1.34 x Hb) x (A - ScvO2) + (PaO2 x 0.003)]
Mixed or Central venous O2 sat
O2 sat of pulmonary a. (Mixed venous blood, SvO2) ➯ Total body O2 consumption
Central line catheter: SVC or IVC
IVC O2 sat > SVC O2 sat (High O2 extraction in brain)
SvO2 depends on Cardiac output
hours in turning
mins in turning