2. Definition Circulatory system failure to supply oxygen and nutrients to meet cellular metabolic demands.

3. Shock Classification and causes: HypovolemicDistributiveCardiogenicObstructivedissociative

5. Hemodynamics Textbook of Pediatric Advanced Life Support, 1988

7. Cardiovascular function Cardiac Output CO = HR x SV HR responds the quickest SV is a function of three variables : preload, After load, myocardial contractility A noncompliant heart cannot increase SV

8. Cardiovascular function 1-Cardiac Output 2-Clinical Assessment peripheral perfusion Temperature capillary refill urine output Mentation acid-base status

9. Hypovolemic shock Definition: Definition: Decreased circulating blood volume. Decreased circulating blood volume. Common causes: Common causes: Hemorrhage Hemorrhage Diarrhea Diarrhea Diabetes insipidus Diabetes insipidus Diabetes mellitus Diabetes mellitus Burns Burns Adrenogenital syndrome Adrenogenital syndrome

10. Distributive shock  Definition  Definition Vasodilation and decreased preload Common causes: SepsisAnaphylaxis Spinal injury Drug intoxication

11. Cardiogenic shock Decreased myocardial contractility Decreased myocardial contractility Common causes: Common causes:  Congenital heart disease  Severe heart failure  Arrhythmia  hypoxic ischemic injuries  Cardiomyopathy  Myocarditis  Drug intoxication  kawasaki

12. Obstructive shock Definition Mechanical obstruction to ventricular outflow. Common causes:  Cardaic tamponade  Massive pulmonary embolus  Tension pneumothorax  Cardiac tumor

13. Dissociative shock Definition Oxygen not released from hemoglobin. Oxygen not released from hemoglobin. Common causes Common causes 1. Carbon monoxide poisoning 2. methemoglobinemia

14. Organ directed therapeutics Cardiovascular support Cardiovascular support Fluid resuscitation Fluid resuscitation Cardiotonic and vasodilator therapy Cardiotonic and vasodilator therapy Respiratory support Respiratory support Renal salvage Renal salvage

15. Cardiovascular Changes in Shock Type Preload Afterload Contractility Cardiogenic    Hypovolemic   No change Distributive    Septic early    late   

16. Evaluation Regardless of the cause: ABC Regardless of the cause: ABC First assess airway patency First assess airway patency ventilation ventilation then circulatory system then circulatory system

17. Evaluation Respiratory Performance Respiratory Performance Respiratory rate and pattern Respiratory rate and pattern work of breathing work of breathing oxygenation (color) oxygenation (color) level of alertness level of alertness Circulation Circulation Heart rate, BP, perfusion, and pulses, liver size Heart rate, BP, perfusion, and pulses, liver size CVP monitoring may be helpful CVP monitoring may be helpful

18. Evaluation Early Signs of Shock Early Signs of Shock sinus tachycardia. sinus tachycardia. delayed capillary refill. delayed capillary refill. fussy, irritable. fussy, irritable. Late Signs of Shock Late Signs of Shock

19. Evaluation bradycardia bradycardia altered mental status (lethargy, coma) altered mental status (lethargy, coma) hypotonia, decreased DTR’s hypotonia, decreased DTR’s Cheyne-Stokes breathing Cheyne-Stokes breathing hypotension is a very late sign hypotension is a very late sign

20. Cardiovascular Assessment (con) CNS Perfusion Recognition of parents Reaction to pain Muscle tone Pupil size Renal Perfusion UOP >1cc/kg/hr

21. Cardiovascular Assessment (con) Skin Perfusion Capillary refill time Temperature Color Mottling

22. Therapy for shock The key therapy is the recognition of shock in its early state. The key therapy is the recognition of shock in its early state. Treating the signs and symptoms. Treating the signs and symptoms. Minimize cadiopulmonary work. Minimize cadiopulmonary work. Ensuring cardiac output blood pressure and gas exchange Ensuring cardiac output blood pressure and gas exchange

23. Hypovolemic Shock Mainstay of therapy is fluid. Mainstay of therapy is fluid. Goals: Goals: 1. Restore intravascular volume 2. Correct metabolic acidosis 3. Treat the cause

24. Hypovolemic Shock (treatment) Degree of dehydration often underestimated Degree of dehydration often underestimated Reassess perfusion, urine output, vital signs... Reassess perfusion, urine output, vital signs... Isotonic crystalloid is always a good choice Isotonic crystalloid is always a good choice 20 to 50 cc/kg rapidly if cardiac function is normal 20 to 50 cc/kg rapidly if cardiac function is normal NS can cause a hyperchloremic acidosis NS can cause a hyperchloremic acidosis

25. Other Studies Look for etiology of shock. Look for etiology of shock. Evaluate hemoglobin, hematocrit, and platelet count. Evaluate hemoglobin, hematocrit, and platelet count. Shock from any etiology can lead to DIC and end organ damage Shock from any etiology can lead to DIC and end organ damage

26. Other Studies CBC, PT, INR, PTT, Fibrinogen, Factor V, Factor VIII CBC, PT, INR, PTT, Fibrinogen, Factor V, Factor VIII Check LFT’s, follow CNS and pulmonary status Check LFT’s, follow CNS and pulmonary status

27. Conclusion Goal of therapy is; Goal of therapy is; identification identification evaluation evaluation and treatment of shock in its earliest stage and treatment of shock in its earliest stage Successful resuscitation depends on early and judicious intervention Successful resuscitation depends on early and judicious intervention Initial priorities are for the ABC’s Initial priorities are for the ABC’s

28. Conclusion Fluid resuscitation begins with 20cc/kg of crystalloid or 10cc/kg of colloid Fluid resuscitation begins with 20cc/kg of crystalloid or 10cc/kg of colloid Subsequent treatment depends on the etiology of shock and the patient’s homodynamic condition Subsequent treatment depends on the etiology of shock and the patient’s homodynamic condition

29. Related infection and shock Infection Infection Bacteremia Bacteremia Systemic inflammatory response syndrome : Systemic inflammatory response syndrome : (2 or>2 of following) (T>38 HR>90 HR>90RR>20 WBC>12000 or 12000 or<4000)

30. Related infection and shock Sepsis: Sepsis: Systemic response to infection Systemic response to infection Sever sepsis: Sever sepsis: sepsis + organ dysfunction sepsis + organ dysfunction (hypo perfusion, lactic acidosis, oliguria,or an acute alter mental status)

31. Related infection and shock Septic shock: Septic shock: sepsis +hypotention despid adequate fluid sepsis +hypotention despid adequate fluid Hypotention: Hypotention: systolic 4reduction systolic 4reduction Multiple organ dysfuntion Multiple organ dysfuntion

33. Burns Disruption 3 key function of skin Disruption 3 key function of skin 1. Regulation of heat loss 2. presevation of body fluid 3. Barrier of the infection

34. Patophisiology Release inflammatory and vasoactive mediators Release inflammatory and vasoactive mediators capillary permeability increase capillary permeability increase Decrease plasma volume and cardiac output Decrease plasma volume and cardiac output Shock is common if borne > 10% -12% Shock is common if borne > 10% -12%

35. classification 1. Depth of injury 2. Percent of body surface area involved 3. Location of the burn 4. Association with other injuries

36. Clinical manifestation 1-First – degree: Red, painful dray Red, painful dray Superficial and limited to epidermis. Superficial and limited to epidermis. Heal in 3-6 days Heal in 3-6 days

37. Clinical manifestation 2-Second degree: Partial-thicking Partial-thicking 1-superficial ( red,painful,blister ) heal in 10- 21 days 2-deep dermal( pale,painful, yellow ) heal in 3 weeks, scarring

38. Clinical manifestation 3-Third –degree: Full thickness,require grafts if >1 cm Full thickness,require grafts if >1 cm Avascular and coagulation necrosis Avascular and coagulation necrosis 4- fourth – degree: Involve underling facia, muscle or bone Involve underling facia, muscle or bone

39. Clinical manifestation Sever burn: Sever burn: >15%Body surface >15%Body surface involves face or prineum involves face or prineum 2 and 3 –degree burns hands or feet circumfrential burn of extermity 2 and 3 –degree burns hands or feet circumfrential burn of extermity inhalation injury inhalation injury

40. Percent of body surface area involved Each upper extremity 9% Each upper extremity 9% each lower extremity 18% each lower extremity 18% Posterior trunk 18% Posterior trunk 18% Anterior trunh 18% Anterior trunh 18% Head 9% and prinium1% Head 9% and prinium1% Location is important : Face, eyes, ears, feet, prinium, hand,full thickness Face, eyes, ears, feet, prinium, hand,full thickness

41. treatment decision is based on : decision is based on : Extent of burn (% burn), body surface (location), type of burn, associated injure, medical complication,availability ambulatory management Extent of burn (% burn), body surface (location), type of burn, associated injure, medical complication,availability ambulatory management Stop the burning process Stop the burning process Fluid and electrolyte support (systemic copillary leak) Fluid and electrolyte support (systemic copillary leak)

42. treatment Significant burn, Second 24 hr dextrose in0.25 normal bolus 20cc/kg lactated Ringer Significant burn, Second 24 hr dextrose in0.25 normal bolus 20cc/kg lactated Ringer Total fluid is 2-4cc/kg/percent burn/24 hr Total fluid is 2-4cc/kg/percent burn/24 hr ( Half in first 8 hr ) that equal 1cc/kg/hr of urine ( Half in first 8 hr ) that equal 1cc/kg/hr of urinesaline Colloid therapy is needed if burn >30% bs and provided after 24 hr with crystalloid Colloid therapy is needed if burn >30% bs and provided after 24 hr with crystalloid

43. treatment Nutritional support: Nutritional support: ( burn produce hypermetabolic response that sedation and analgesic can decrease) ( burn produce hypermetabolic response that sedation and analgesic can decrease) In critical burn parenteral nutrition Enteral feeding résumé on 2-3 days

44. treatment Wound care: Wound care: Relief any pressure on cerculation Relief any pressure on cerculation Covered with sulfadiazin Covered with sulfadiazin Graft Graft Tetanus toxoid in incomplete immunization Tetanus toxoid in incomplete immunization

45. hospitalization Extended of burn in children Extended of burn > 10% in children Body surface area involved: Body surface area involved: Face,neck, both hands, both feet,prineum Type of burn; electrical contact,chemical Type of burn; electrical contact,chemical Association injuries; Association injuries; Soft tissue trauma, fractures,smoke inhalation head injury.

46. hospitalization Complicating medical problems Complicating medical problems Diabetes,heart disease, pulmonary disease, ulcer history. Diabetes,heart disease, pulmonary disease, ulcer history. Social problem. Social problem. Suspected child abuse or neglect, self infected burn, psycologic problems

47. Burn Complication Sepsis ( avoid prophylactic antibiotic) Sepsis ( avoid prophylactic antibiotic) Hypovolemia, hypothermia Hypovolemia, hypothermia laryngeal edema laryngeal edema carbon monoxide injury carbon monoxide injury (100% o2,hyper baric o2) cardic disfunction cardic disfunction gasteric ulcer gasteric ulcer

48. Burn Complication compartment syndrome compartment syndrome contracture contracture hyper metabolic state hyper metabolic state renal failure renal failure anemia anemia psychological trauma psychological trauma pulmonary infiltration,pulmonary edema, pneumonia,bronchospasm pulmonary infiltration,pulmonary edema, pneumonia,bronchospasm