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

2. 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!!!

3. Shock in Pediatrics Types: Hypovolemic Distributive Cardiogenic
Obstructive

4. 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”)

5. 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)

6. 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)

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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

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

17. 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!!

18. 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!

19. 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

20. 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

21. 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

22. 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

23. 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?

24. 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

25. 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

27. 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,

28. Questions ???