3. DEFINITION
An acute, complex state of circulatory
dysfunction that results in failure to deliver
sufficient amount of oxygen and nutrients to
meet tissue metabolic demands.
Therefore, basically DO2 < VO2.
If prolonged and left untreated- Can lead to
multiple organ failure and eventually death.
4. igure 1. FACTORS AFFECTING OXYGEN DELIVERY
DO2
CaO2
CO
SV
HR
Oxygenation
Hgb
A-a gradient
DPG
Acid-Base Balance
Blockers
Competitors
Temperature
Drugs
Conduction System
Ventricular
Compliance
EDV
ESV Contractility
CVP
Venous Volume
Venous Tone
Afterload Blockers
Temperature Competitors
Drugs Autonomic Tone
Metabolic Milieu
Ions
Acid Base
Temperature
Drugs
Toxins
Influenced By
Influenced By
Influenced By
Influenced By
5. What is needed to maintain
Perfusion??
PUMP- Heart
PIPES- Vessels
FLUID- Blood
Pump Failure
Pipe Failure
Loss of Volume
How can Perfusion fail??
8. PHASES OF SHOCK
Compensated Shock
- Intrinsic regulatory mechanisms
- Vital organ function is maintained
Uncompensated Shock
- Compromise of microvascular perfusion
- Deterioration of organ function
- Hypotension develops
Irreversible Shock
- Damage to key organs
.
10. Recognition & Assessment..
Neurological
-Full/ flat/ sunken fontanelle
-Calm/ anxious/ irritable
-Alert/ lethargic
-Responsive to parents
-level of consciousness
-Muscle tone
-pupillary size
Renal
- Urinary output
11. SIGNS OF SHOCK
Early Signs
1. Tachycardia
2. Normal blood pressure
3. Mildly delayed capillary refill
4. Fussy child
12. Signs of Shock..
Late Signs
1. Persisting tachycardia or bradycardia
2. Hypotension- LATE sign!!
3. Poor capillary refill
4. Altered mental status
5. Irregular breathing pattern
6. Poor muscle tone
7. Lower limit of SBP=70 + (2 x age in years)
15. HYPOVOLEMIC SHOCK
MCC of shock in children
Decrease in the intravascular blood volume to
such an extent that effective tissue perfusion
cannot be maintained.
Preload decrease
Decreased Stroke Volume
Decreased C.O.
16. Management of Hypovolemic
Shock
Establishment of adequate oxygenation and
ventilation
O2- ALWAYS the first drug administered.
Adequate IV or IO
Early correction of hypovolemia
-Crystalloids: Readily available, safe, least expensive
-First bolus 20cc/kg- ASAP
-Continuous monitoring of vitals
-Monitoring of CVP: Maintain > 10mmHg
-Identify causes of ongoing losses
- Blood available: if hemorrhagic shock.
18. The Stages of Shock
Normal Eucardia, normal BP and CR
Tachycardia alone, normal BP and CR
HR is maintaining CO despite reduced stroke volume (CO =
HR x SV)
Hypotension with normal CR = Warm shock
Vascular tone cannot maintain blood pressure but HR maintains
CO
Prolonged CR with normal BP = Cold shock
HR does not maintain CO but vascular tone maintains BP
Prolonged CR + hypotension = Decompensated Cold Shock
HR does not maintain CO and vascular tone does not maintain
(Carcillo et al., Pediatrics 2009)(Slides are courtesy of Dr. Carcillo)
19. CARDIOGENIC SHOCK
1. a. Toxic substances released during
course of shock.
b. Myocardial Edema
c. Adrenergic receptor dysfunction
d. Impaired sarcolemmic Calcium flux
e. Reduced coronary blood flow
2. Diastolic Dysfunction
20. Pathophysiology
LV able to eject less volume of bld/ beat
Dec. Stroke Volume
Increased Venous Return
Increased EDV
Increased LV diastolic filling pressure
Backflow from LV to lungs
Dec.C.O
Increased O2
extraction by
tissues
Arterial O2
desaturation
24. OBSTRUCTIVE SHOCK
Normal Preload
Normal myocardial function
Inadequate C.O.
Etiology
Recognize and treat underlying cause!!
Tension Pneumothorax
Pulmonary/ Systemic HTN
Congenital/ Acquired outflow
obstructions
Ac. Pericardial Tamponade
25. DISTRIBUTIVE SHOCK
PathoPhysiology:
a. Maldistribution of blood flow to tissue due to abnormal
vasomotor tone.
b. Profound inadequate tissue oxygenation.
c. Normal or High C.O.
Etiology
Management: Recognize and treat underlying cause
Anaphylaxis
Spinal or Epidural anesthesia
Disruption of spinal cord
Iatrogenic
28. SIRS Sepsis Severe
Sepsis
Septic Shock
Systemic
inflammatory
response to variety
of severe clinical
insults indicated by
2 or more of the
following:
Temp > 38 or < 36
HR > 90bpm
(adults)/ >2SD(ped)
RR > 20/min
(adults)/>2SD(ped)
OR PACO2
<32mmhg
WBC>12000,
<4000 or > 10%
bands
Systemic response
to infection
manifested by 2 or
more of the following
as a result of
infection:
Temp > 38 or < 36
HR>90
RR>20 or PaCO2 <
32
WBC>12000.
<4000 or >10%
bands
Sepsis associated
with:
Organ dysfunction
Hypoperfusion
(Lactic acidosis,
oliguria, altered
mental status)
Hypotension
29. Warm Shock Cold Shock Fluid-Refractory/
Dopamine resistant
Catecholamine
Resistant
Refractory Shock
Early,
compensated
Clinical Signs
-Inc.HR
-Warm
extremities,
bounding pulses
Physiologic
Parameters
-Wide PP
-Inc. C.O.
-Inc. MvO2
-Dec.SVR
Lab Data
-Hypocardia
-Inc. Lactate
-Inc.Glucose
Late, Uncompensated
Clinical Signs
-Cold, clammy extremities
-Rapid, thready pulses
-Shallow breathing
Physiologic Parameters
-Narrow PP
-Dec.CVP, C.O
-Dec. MvO2 sat
-Inc. SVR
-Oliguria
-Capillary Leak
Lab Data
-Metab. Acidosis
-Hypoxia
-Coagulopathy
-Hypoglycemia
Persistance of shock
despite > 60cc/kg
fluid resuscitation
Persistance of shock
despite Dopamine at
>10mcg/kg/mn
Persistance of shock
despite administration of
direct acting
catecholamines
Epinephrine/
Nor-Epinephrine
Persistance of shock
despite:
-Goal direct inotropic/
pressor therapy
-Use of vasodilators
-Maintenance of
metabolic and
hormonal homeostasis
30.
31. Early Goal directed therapy in treatment of sepsis and septic shock- Rivers et al., NEJM, Nov 2001
32. Community-Acquired Sepsis
Pneumonia-Quinolone PLUS B-lactam
Abdominal-Carbapenem OR Pip-Tazo
Skin/Soft Tissue-Vanco PLUS Carbapenem or Pip-Tazo
Urinary Tract-Quinolone PLUS Amp/Vanco
Unknown-Vanco PLUS B-lactam
Health-Care Associated Sepsis
Lung-B-lactam PLUS Vanco
Bloodstream -B-lactam PLUS Vanco +/- Antifungal
Surgical Site -B-lactam PLUS Vanco +/- Anaerobic coverage
Suspected Candida-Caspofungin
Unknown-B-lactam PLUS Vanco
Antibiotic Guidelines in Sepsis by Suspected SiteAntibiotic Guidelines in Sepsis by Suspected Site
33. HEMODYNAMIC VARIABLES IN
SHOCK STATES
↑ or ↔↑↓↓↑↑↓↓Septic: Late
↓↓↔ Or ↓↓↓↓↑↑↑Septic: Early
↔ Or ↓↔ Or ↓↔ Or ↓↓↓↓↑↑Distributive
↑↑↑↑↔ Or ↓↑↓Obstructive
↑↑↑↑↔ Or ↓↑↑↑↓↓Cardiogenic
↓↓↓↓↓↓↔ Or ↓↑↑Hypovolemic
CVPWedgeMAPSVRCO
34. B.P or Systemic Vascular Resistance
Therapies for Hemodynamic Patterns in Shock
State
35. Therefore, the Basics….
Stabilize respiration
Assess perfusion
Fluid administration
IV Access
Vasopressors
Inotropic therapy
Red blood cell transfusions if needed
Diastolic dysfunction-Impaired myocardial relaxation changes the press-vol raio during diastole and increases ventricular pressure at any vol. This lack of relaxation is hemodynamically unfavorable because Inc LV diast pressure is transmitted to the lung anf results in pulm edema and dyspnea. Elev LV diastolic press also dec myocardial perfusion pressure and can lead to subendocardial iscehmia. Can have normal &lt;V systolic function.
Optimize Preload- Salt and water restriction, Fluid challenges, diuretics/venodilators for congestion
Improve Contractility- Provide O2, guarantee ventilation, correct acidosis and other metaboilc derangements, inotriopic drugs
Reduce Afterload- Provide sedation, pain relief, correct hypothermia, vasodilators