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Presented By
• HYPOVOLEMIC
• Water Loss (diarrhea, vomiting with poor PO
intake, diabetes, major burns)
• Blood Loss (obvious trauma; occult bleeding
from pelvic fractures, blunt abdominal trauma)
• SEPTIC
Bacterial, viral, fungal.
Clinical classification of shock
CARDIOGENIC
Cardiogenic shock may occur
as a complication of—
• Severe cardiac dysfunction
before or after cardiac surgery
• Congenital heart disease
• Severe burn
• Arrhythmia
• Cardiomyopathy
• Myocarditis
• Myocardial infarction
• Acute central nervous system
disoder
• DISTRIBUTIVE- Etiologies
• Anaphylaxis
• Anaphylactoid reactions
• Spinal cord injury/spinal
shock
• Head injury
• Early sepsis
• Drug intoxication--
Barbiturates,
Phenothiazines,
Antihypertensives
• OBSTRUCTIVE
Causes:
•Pericardial tamponade
•Tension pneumothorax
•Critical coarctation of
the aorta
•Aortic stenosis
•Hypoplastic left heart
syndrome
PATHOPHYSIOLOGY
Extracorporeal fluid Hypovolemic shock may be due to direct blood
loss loss through hge or abnormal loss of body fluids
Urinary Sp Gravity
Circulation
– Based on presumed etiology
– Rapid restoration of intravascular volume
• PIV-if unstable you have 60-90 seconds
• I.O. if less than 4-6 years old
• Central venous catheter
• Use isotonic fluid: NS, LR, or 5% albumin
• PRBC’s to replace blood loss or if still unstable after
60cc/kg of crystalloid
– anemia is poorly tolerated in the stressed, hypoxic,
hemodynamically unstable patient
GENERAL MANAGEMENT OF
SHOCK
Sign of hypoperfusion Airway, ventilation,IV access.
Send blood for investigations
If signs of hypoperfusion persist, reasses the patient for further evaluation and
management
Assess and maintain ABC within 5 min
If no improvement
2nd bolus 20 ml/kg over 15-20 min
3rd bolus 20ml/kg over 15-20 min
BLOOD
PRESSURE
PERIPHERAL VASCULAR
CARDIAC OUTPUT RESISTANCE
Hemorrhagic Shock
Treatment is PRBCs or whole blood
– Treat the cause if able (stop the bleeding)
– Transfuse if significant blood loss is known or if patient
unstable after 60ml/kg crystalloid
Special situation
Heamorrhagic shock encephalopathy
syndrome
• Unusual form of shock initially look similar to heat stroke
• Seen in children younger than 3 yr old
• Characterized by encephalopathy, fever, shock, watery
diarrhoea, DIC and renal and hepatic dysfunction
• May develop seizure and other severe neurologic finding
due to cerebral edema
• Treatment- fluid therapy and supportive care for renal and
hepatic function
• Mortality high and survivors have high incidence of
neurologic problems.
SEPTIC SHOCK
Septic shock is defined as sepsis plus
cardiovascular organ dysfunction
manifested by the persistence of
hypoperfusion or hypotension for > 1 hr
despite adequate fluid resuscitation or a
requirement for inotropic agents or
vasopressors.
infants and
children children with
3 mo to 3 yr serious injuries
children on
chronic anti- Who malnourishedc
hildren
bacterial therapy
are at
risk ?
In older children
Streptococcus pneumoniae
Neisseria meningitidis
Staph aureus(methicillin sens or resistant)
Septic shock
Intravascular fluid
losses occurs Myocardial- Result of decreased
through capillary depressant effect systemic vascular
leak of sepsis resistance
PATHOGENESIS
• It is important to distinguish between the infection and host
response to the infection, the inflammatory process.
• This host immune response produces an inflammatory cascade of
highly toxic mediators, including hormones, cytokines, and
enzymes.
• If this inflammatory cascade is uncontrolled, SIRS occures with
subsequent organ and cellular dysfunction from derangement of
microcirculatory system
PATHOPHYSIOLOGY OF SEPTIC
PROCESS
Superantigens and
Focus of infection
endotoxin
Activation of Activation of
complement system coagulation system Endogenous mediator release
Pro-inflammatory cytokines
Activated endothelium-increased Anti-inflammatory cytokines
expression of endo derived adhesion Platelet activating factors
molecule Arachidonic acid metabolite
Myocardial depressant
Decreased thrombomodulin, increased substance
plasminogen activator inhibitor Endogenous opiates
Thrombosis and antifibrinolysis
5-15 minutes
Push 20ml/kg isotonic crystalloid or colloid up to and over 60ml/kg
Correct hypoglycemia and hypocalcemia
Fluid refractory
Fluid responsive Establish central venous pressure, start dopamin10-
shock -observe 20µgm/kg /min, establish arterial monitoring
60 min
Catecholamine responsive-observe Catecholamine resistant shock
At risk for adrenal insufficiency?
Normal blood
pressure, cold Yes No
shock, SVC sat Give hydrocortisone 50 mg/kg/day
<70%
Low blood pressure, cold Low blood pressure warm shock
shock, SVC SO2< 70%
Add vasoilatory or
type III Titrate volume and
phosphodiesterase Titrate volume and norepinephrine
inhibitor, plus epinephrine-observe Low dose vasopressin
volume observe observe
BLOOD PRESSURE
When digoxin is required for these pt, a lower and less frequent dosage should be
used and S. digoxin level must be monitored frequently.
• Pt with deteriorating cardiogenic shock may
benefit from
-Left ventricular assist device(LVAD)
- Right and left ventricular assist
device(BiVAD)
- Extracorporeal membrane
oxygeation(ECMO)
- Heart transplantation
Obstructive Shock
• Low CO secondary to a physical
obstruction to flow
• Compensatory increased in SVR
• Initial clinical presentation can be identical
to hypovolemic shock
• Initial therapy is a fluid challenge.
•Initial therapy is a fluid challenge
•Treatment of underlying cause
-pericardial drain, chest tube, surgical
intervention
-if the patient is a neonate with a ductal
dependent lesion then give PGE
•Further evaluation, invasive monitoring,
pharmacologic therapy, appropriate consultation to
be done according to cause
Distributive Shock
• It is characterized by high CO and low SVR (opposite
of hypovolemic, cardiogenic, and obstructive)
• Maldistribution of blood flow causing inadequate
tissue perfusion
• Due to release of endotoxin, vasoactive substances,
complement cascade activation, and microcirculation
thrombosis
• Early septic shock is the most common form
Distributive Shock
BLOOD
PRESSURE
PERIPHERAL VASCULAR
CARDIAC OUTPUT RESISTANCE
A. Hypovolemic shock
-volume expansion using intravenous
crytalloid.Colloids are to be used with caution.
-Blood replacement therapy
B. Septic shock
-obtain blood culture
- give empiric antibiotic therapy
-volume expansion and inotropic agent
-Use of steroid is controversial
C. Cardiogenic shock:
-Treat arrhythmia if present
-correct metabolic causes
- Give inotropes: Dopamine is drug of first choice. If
dopamine fails to improve BP, Dobutamine is
recommended as second line drug. In neonates, it is usually
given together with dopamine infusion.
- Epinephrine and isoproterenol are sometimes used.
D. Neurogenic shock:
- volume expansion and inotropic agents
E. Drug induced hypotension:
-volume expansion
- discontinuation of offending drugs
F. Endocrine disorder:
- Adrenal hge is treated with volume
expansion, blood replacement and corticosteroids
- Congenital adrenal hyperplasia is treated with
corticosteroid.
G. Hypotension of ELBW infants
- antenatal steroid
-physiologic doses of hydrocortisone
- dopamine
PEM with shock
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