Kids Rock Shock! Recognizing Shock in Children Jackie Williams-Connolly RN Laila Brown BN, RN Janeway Emergency October 2013

What is Shock? Circulatory system failure to supply oxygen and nutrients to meet cellular metabolic demands Results from inadequate tissue perfusion Shock is the most reversible cause of death in children!!!

Shock in Pediatrics Types: Hypovolemic Distributive Cardiogenic Obstructive

a result of blood and/or body fluid loss Hypovolemic Shock: a result of blood and/or body fluid loss # 1 cause of death in children worldwide Causes Water Loss (diarrhea, vomiting with poor PO intake, diabetes, major burns) Blood Loss (obvious trauma; occult bleeding from pelvic fractures, blunt abdominal trauma, “shaken baby”)

A result of excessive vasodilation and Distributive Shock: A result of excessive vasodilation and the impaired distribution of blood flow Causes: Occurs when the blood vessels dilate, resulting in poor distribution of blood flow or volume The vasodilation and venodilation cause pooling of blood in the venous system Most common forms of distributive shock are Septic shock Anaphylactic shock Neurogenic shock (spinal injury)

Results from ineffective tissue perfusion Cardiogenic Shock: Results from ineffective tissue perfusion caused by inadequate contraction of the cardiac muscle Causes: Congenital heart disease Myocarditis (inflammation of heart muscle) Cardiomyopathy (an inherited or acquired abnormality of pumping function) Dysrhythmias Myocardial injury (trauma)

Results from an inadequate circulating blood volume Obstructive Shock: Results from an inadequate circulating blood volume Causes: Because of a physical obstruction or compression of the great veins, aorta, pulmonary arteries, or the heart Cardiac tamponade Tension pneumothorax Massive pulmonary embolism

Hemodynamic definitions of shock Cold Shock Depressed level of consciousness Capillary refill > 2 secs Diminished peripheral pulses Mottled cool extremities Decreased urine output Warm Shock Depressed level of consciousness Flash capillary refill Bounding peripheral Pulses Decreased urine output

Stages of Shock Death Refractory (Irreversible) Hypotensive/ Initial Compensated Hypotensive/ Decompensated Refractory (Irreversible) Death

Initial Cardiac output is decreased and tissue perfusion is impaired decrease blood supply (oxygen) to the cells Anaerobic metabolism decreases energy but increases lactic acid Lactic acidemia (metabolic acidosis) quickly causes more cellular damage Minimal changes in Vital Signs Normal BP

KEYS to Early Shock Recognition ALTERED MENTAL STATUS Irritable, inconsolable Does not interact with parent Stares into space Poor response to pain ABNORMAL PERFUSION Decreased or bounding peripheral pulses Poor capillary refill Decreased urine output

Compensatory The patient in this stage of shock has very few symptoms, and treatment can completely halt any progression low blood flow (perfusion) is first detected (Capillary Refill) Multiple systems are activated in order to maintain/restore perfusion Heart rate increases

Vasoconstriction-changes in skin color & pulses The kidney works to retain fluid in the circulatory system All this serves to maximize blood flow to the most important organs and systems in the body BP is not a good indicator: Could still be normal Children can lose up to 25% of fluid volume before we see a change

Hypotensive/Decompensated Methods of compensation begin to fail The systems of the body are unable to improve perfusion any longer, and the patient's symptoms reflect that fact Oxygen deprivation in the brain causes the patient to become confused and disoriented, while oxygen deprivation in the heart may cause chest pain With quick and appropriate treatment, this stage of shock can be reversed.

Refractory/Irreversible the length of time that poor perfusion has existed begins to take a permanent toll on the body's organs and tissues The heart's functioning continues to spiral downward, and the kidneys usually shut down completely Cells in organs and tissues throughout the body are injured and dying Complete failure of compensatory mechanisms Death even in the presence of Resuscitation

WARNING !!! Blood pressure may be normal in early, compensated shock Normal Bp = 70 + 2X age ( 1-10 yrs) Low blood pressure does not occur until LATE shock Tachycardia is a non-specific sign of distress

LATE SHOCK Vital Signs: Tachycardia Tachypnea Hypotension Exam Findings: Agitated, confused, decreased LOC Poor tone Tacky mucous membranes Cool, mottled extremities Decreased pulses Delayed capillary refill, >4 seconds Late Shock is a Pre-arrest State!!

Death even in the presence of Resuscitation If symptoms of shock are missed If treatments are inadequate or delayed Shock progression is typically an “accelerating condition” It may take hours for compensated shock to progress to hypotensive shock Only minutes for hypotensive shock to progress to cardiopulmonary failure and cardiac arrest!

Treatment of shock ABC’S IV/IO access ! ( don’t waste valuable time on IV access, IO very practical in kids) Fluids : 20 ml/kg over 5-10 minutes (unless Cardiac involvement is suspected then 5-10 ml/kg always reassess chest sounds/CXR for signs of fluid overload) USE N/S (preferred) or R/L (if no Renal Problems due to K) Too much fluid can cause Cerebral Edema (esp. in DKA) Antimicrobial coverage is essential Steroids (2MG/KG TO MAX 100MG) Consider inotropic and vasoactive agents Good History from family (SAMPLE) Always reassess your patient, their treatments and the plan

Anti Microbial Treatment is essential to increase survival rates: Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock

Case Study: 4 month old male, previously well Parents state he has had fever, vomiting and diarrhea for the past two days Today, extremely fussy and refusing feeds One wet diaper over the past 12 hours

Case Study: Physical Exam Toxic-appearing infant, irritable, does not console T-39.6 HR-206 RR-66 BP-129/109 Sat probe is not picking up well Tacky mucous membranes Sunken fontanel Palpable femoral pulse, thready peripheral pulses Extremities cool and mottled

Case Study: What history is concerning? What exam findings are concerning? What stage of shock is this infant in? What type of shock? How do you start management?

Treatment: You place the baby on oxygen You are able to insert a peripheral IV What if you can’t get an IV? IO? What fluids and how much? Antimicrobials

Treatment & Goals: Reassessment You estimate the baby is 5 kg and give NS 100ml rapidly Infant still fussy and mottled You give a second NS bolus of 100mL On reassessment, somewhat fussy, alert HR-180 RR-30 BP-130/100 O2sat 100% on 100%O2 cap refill <2s

Reassess, Reassess, Take Home Points: Shock is the most reversible cause of death in children BP has little to do with early shock recognition It is NOT OK to sit on a patient who has compensated shock Late shock is a pre-arrest state The majority types of Shock is fluid responsive Shock is a major cause of morbidity and mortality in pediatric patients Early and aggressive management leads to improved outcomes! Reassess, Reassess,

Questions ???