Recognizing Shock

Objectives Know the definition of shock Recognize the signs & symptoms of shock Recognize that there are different types of shock Discuss interventions/treatment of shock Understand the differences in neonates

What is Shock? Shock is a clinical state in which the delivery of oxygen and substrates is insufficient to meet the demands of the body

What is Shock? DEATH What are the results of shock? Tissue hypoxia/cellular dysfunction Metabolic acidosis Organ dysfunction/failure DEATH

What is Shock? For each hour that shock persists without treatment, the mortality rate goes   !

What is Shock? In most cases of shock, the patient’s cardiac output is insufficient to adequately perfuse the body’s organs.

What is Shock? Goals in treating shock Restore intravascular volume Treat any myocardial dysfunction Treat vascular insufficiency In order to ↓ HR and ↑ BP Improve perfusion ↓ metabolic acidosis ↑ urine output

Signs and Symptoms of Shock ASSESSMENT PARAMETERS General appearance Capillary refill Pulses Vital signs Urine output Questions to ask

Signs and Symptoms of Shock General Appearance What does the patient look like? Evaluate mental status

Signs and Symptoms of Shock Capillary Refill Evaluate skin perfusion by checking capillary refill and skin color Capillary refill is evaluated by positioning the extremity just above the heart level, pressing a finger on the palm of the hand or the bottom of the foot, letting go and then counting how long it takes the color to return to the extremity Interpret capillary refill in conjunction with other signs of shock as it is a poor indicator when used alone

Signs and Symptoms of Shock

Signs and Symptoms of Shock Is this a sign of poor perfusion?

Signs and Symptoms of Shock YES !!!!!

Signs and Symptoms of Shock Pulses Evaluate pulses

Signs and Symptoms of Shock How do you compare pulses??? Palpate peripheral & central pulses & compare Femoral & Pedal Or Brachial and Radial Are they ? Weak /Thready Normal Bounding Absent Note: A patient will lose peripheral pulses before they lose central pulses

Signs and Symptoms of Shock Vital Signs Evaluate vital signs They are called vital signs because…..

…….they are REALLY, REALLY important!!!!! Signs and Symptoms of Shock …….they are REALLY, REALLY important!!!!!

Signs and Symptoms of Shock In order for vital signs to be helpful you need to know Absolute number Context or clinical scenario Trends

Signs and Symptoms of Shock Absolute number Is the number normal or abnormal?

Signs and Symptoms of Shock Context What is the child doing? (i.e., sleeping, playing, etc.) What is the clinical condition the child is in? (i.e., dehydration, fever, anemia, hypoxia, pain, anxiety, etc.)

Signs and Symptoms of Shock Trends Are the vital signs: Improving? Stable? Deteriorating?

Signs and Symptoms of Shock Stable means Unchanging or static It does not automatically mean normal or good Remember, death is a stable state!

Signs and Symptoms of Shock HEART RATE You must evaluate the heart rate in the context and clinical state of the child. Is he running around ? Is he febrile? Is he crying?

Signs and Symptoms of Shock HEART RATE Rate normally decreases as child’s age increases Tachycardia is the body’s response to stress Note normal ranges on Vital Sign Reference Sheet (see next slide)

PEDIATRIC VITAL SIGNS REFERENCE CHART AGE WT. (KG) PULSE RESPIRATORY RATE SYSTOLIC BP DIASTOLIC BIRTH   2.7 - 4 100 – 180 35 50 – 70 16 – 36 1 MONTH 4 100 – 220 30 60 – 90 20 – 60 6 MONTHS 7 80 – 150 87 – 105 53 – 66 2 YEARS 12 - 14 25 95 – 105 4 YEARS 16 - 18 70 –110 23 6 YEARS 20 - 26 70 – 110 21 7 YEARS 97 – 112 57 – 71 8 YEARS 20 10 YEARS 32 - 42 55 – 90 19 ADOLESCENT > 50 55 - 90 115 – 128 66 - 80  Normal Values: Systolic BP 1 to 7 years (age in years + 90) 8 to 18 years ( 2 x age in years + 83)   Diastolic BP 1 to 5 years (56) 6 to 8 years ( age in years + 52)

Signs and Symptoms of Shock HEART RATE CO = HR X SV CO = cardiac output (volume of blood ejected by the heart each minute) HR = heart rate SV = stroke volume (volume of blood ejected per beat) The body attempts to compensate for a decreasing stroke volume by increasing the heart rate

Signs and Symptoms of Shock BLOOD PRESSURE Measure systolic BP & diastolic BP Calculate pulse pressure (sBP – dBP = Pulse Pressure) Why?… It is important to identify a widened pulse pressure because it may be an early sign of shock. If you wait to respond, it may result in a decrease in BP & narrow pulse pressure Documenting “unable to obtain ” when measuring BP is unacceptable

Hemodynamic Response to Shock 140 100 60 20 Vascular Resistance BP = CO x VR As the CO ↓ the HR & VR ↑ This enables the body to maintain a normal BP THIS IS A KEY DIFFERENCE BETWEEN CHILDREN & ADULTS Percent of control Slide 11: Hemodynamic Response to Shock in Infants and Children This figure illustrates typical changes in heart rate, blood pressure, and cardiac output as the child moves from compensated to decompensated (ie, hypovolemic to hypotensive) shock. Note that tachycardia without hypotension is present in compensated shock. Blood pressure is initially maintained through an increase in systemic vascular resistance. As cardiac output falls further, blood pressure begins to fall, and shock is characterized as decompensated shock. Cardiac Output Blood Pressure Decompensated or Late Shock Compensated or Early Shock

Signs and Symptoms of Shock BLOOD PRESSURE Hypotension typically develops before loss of central pulses Hypotension is an ominous sign. If it is not treated promptly it will lead to cardiopulmonary failure/arrest

Signs and Symptoms of Shock Urine Output Evaluate urine output Urine output is a good indicator of renal perfusion, but do not use the initial measurement of urine

Signs and Symptoms of Shock How to calculate normal urine output

Signs and Symptoms of Shock Assessment Questions Does my patient have normal perfusion? What is the capillary refill? How do the central and peripheral pulses compare? What is the HR and BP? Is the patient improving? What is my patient’s mental status? Is my patient urinating? Is it adequate?

Types of Shock Hypovolemic Shock Cardiogenic Shock Neurogenic shock – inadequate intravascular volume - most common Cardiogenic Shock - characterized by myocardial dysfunction Neurogenic shock – characterized by nervous system dysfunction Anaphylactic shock – life threatening exposure to an allergen

Types of Shock Septic shock has three components: Systemic inflammatory response Infection Poor perfusion and hypotension

Types of Shock Systemic Inflammatory Response Syndrome > 2 of the following: Abnormal temperature Tachycardia Tachypnea or respiratory alkalosis Abnormalities of WBC

Types of Shock PHYSIOLOGIC CLASSIFICATION OF SHOCK EARLY LATE Signs of inadequate tissue/organ perfusion Normal BP LATE Signs of inadequate tissue and/or organ perfusion Hypotension

Types of Shock Irreversible Shock Complete failure of the body’s compensatory mechanisms Death occurs even in the presence of resuscitation measures

Types of Shock Early Shock What will the body do to try and compensate?

Types of Shock Have a catecholamine surge which results in…. Tachycardia ↑↑ systemic vascular resistance Cool, pale, mottled skin Capillary refill > 2 seconds Weak, thready peripheral pulses

Types of Shock What else ? Blood pressure changes Increased respiratory rate Patient may be irritable, sleepy, lethargic May see a decrease in urine output Blood pressure changes Systolic is normal or even high Diastolic may be low

Types of Shock Late/Decompensated Shock Defense mechanisms begin to fail The patient may exhibit: Hypotension Prolonged capillary refill Tachycardia or (bradycardia – ominous sign) Absent peripheral pulses Rapid, thready central pulses Decreased level of consciousness

Interventions/Treatments Provide O2 and mechanical ventilation FLUID RESUSCITATION 20ml/kg NS boluses (note the plural) Vasoactive infusions (ie. dopamine) Treat metabolic abnormalities

Interventions/Treatments Clinical Strategies Know your patient’s history Know normal vs abnormal and look for abnormalities Know your patient’s vital sign trends Think the “worst case scenario” and then rule it out

Interventions/Treatments Clinical Pearls Know and look for these early warning signs ↑HR - the most commonly ignored abnormal vital sign is tachycardia Peripheral perfusion abnormalities dBP – look for diastolic hypotension and look at the pulse pressure

Interventions/Treatments You MUST do FREQUENT, RAPID REASSESSMENTS of the patient’s hemodynamic status and DOCUMENT everything!

Neonates If children are different from adults, then neonates are something else entirely.

Neonates Differences in the neonate We are talking about patients with an age of < 28 days Limited cardiac reserve Limited respiratory reserve Limited metabolic reserve

Neonates Take home message for neonates……… Neonates can go into a shock state faster than children and adults. Neonates have less tolerance for shock states than children and adults. You must identify and treat shock immediately!

Message from Dr. Hernan Recognize shock and label it Rapidly and repeatedly assess hemodynamics Mortality is related to persistent shock Be appropriately aggressive with fluids and vasoactive infusions Intubate and mechanically ventilate early Remember the neonate Jump start the circulation or patients die

SHOCK – Reference Chart EARLY LATE Respiratory Rate Increased Bradypnea - ominous Heart Rate Bradycardia - ominous Pulse Quality Decreased to thready Bounding in Septic Peripheral pulse may be absent Central decreased Capillary Refill Prolonged >2 seconds Prolonged LOC Normal to altered Altered mental status BP Normal Hypotensive Urine Output Decreased Anuric

REFERENCES: Carcillo JA: Task force Members, Fields al REFERENCES: Carcillo JA: Task force Members, Fields al. Clinical practice Parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 30(6):1-13, 2002 Hernan, Lynn J., MD, “Vital Signs” , “Recognition and Treatment of Pediatric Shock” Kaleida Health Corporate Nursing Policy, Pediatric Vital Signs. PED.5PTC PALS Provider Manual (2002). American Heart Association, Dallas, Texas AHA, PALS Instructor Manual, 2001 Whaley, Lucille F. and Wong, Donna L. (2003). Nursing Care of Infants and Children, 7th Edition, C.V. Mosby Company, St. Louis