Shock in

pediatric

EM1-K13

Shock
A state of circulatory dysfunction that fails
to provide sufficient oxygen and nutritions
to meet the metabolic needs of vital
organs and peripheral tissues

Oxygen Delivery
DO2 = CaO2 x CO
CaO2= (Hgb x 1.34 x SaO2) +
(0.003 x PaO2)
CO = HR x SV

Sign of shock state & progress

Compensated
Inadequate end
organ perfusion
Tachycardia
Cool extremities
Prolonged capillary
refill
Weak peripheral
pulses
Normal blood
pressure

Depressed mental
status
Decreased urine
output
Metabolic acidosis
Tachypnea
Weak central pulses

Decompensate
d

Hypotension

Major categories of shock

Hypovolemic

Cardiogenic

Distributive

The most common type; circulating

intravascular blood volume
decrease; decrease in preload;
decrease CO
Heart rate abnormalities (heart
block, ventricular, supraventricular
tachycardia), decreased myocardial
contractility
Relative uncommon; maldistribution
of tissue blood flow due to
decreased systemic vascular
resistance,
Extrinsic force acting on

Etiology and typical

presentation of
Hypovolemic Shock

Etiology

Diarrhea
Blood loss (traumatic)

Presentatio Tachycardia
Narrowed pulse
n
pressure
Delayed capillary refill
Cool extremities
Late stages:
hypotension

Etiology

Etiology and typical

presentation of
Cardiogenic
Shock
CHD, cardiomyopathies,

myocarditis, coronary infark

Dysrhytmia
Acidosis, hypoxic-ischemic,
poisoning, metabolic disorders
Prolonged shock
Sepsis

Presentatio Bradycardia/tachycardia
Gallop
n
Barely perceptible pulses
Cardiomegaly
Rales

Etiology

Etiology and typical

presentation of
Distributive Shock

Presentation

Early septic Shock

Anaphylaxis
Toxic ingestion
Spinal/ epidural anesthesia
Head/spinal cord injuries
Flush appearance
Warm extremities
Bounding pulses
Tachycardia
Wide pulse pressure
Capillary refill may be
instantaneous

Etiology

Etiology and typical

presentation of
Obstructive Shock

Presentatio
n

CHD (Aortic stenosis/

coarctation)
Tension pneumothorax
Hemopneumothorax
Pericardial effusion
Tachycardia
Cool extremities
Delayed capillary refill
Narrow pulse pressure
Distended neck veins, distant
heart tones, asymmetric breath
sounds

Evaluation of shock

Assesment of Airway, breathing and

circulation
Blood glucose
History and physical examination

Assesment of airway, breathing and

circulation
Airway
Airway patency
Breathing

Circulation

Respiratory rate
Respiratory pattern
Work of breathing (respiratory
distress)
Continuous pulse oxymetry
Bradycardia
Tachycardia
Rhythm abnormalities
Central and distal pulse
Capillary refill (normal : complete
between 2 to 3 seconds)
Hypotension (late finding)

Normal respiratory rates in children

Age
Newborn-1
year
1-3 years
3-12 years
>12 years

Respiratory rate
(breaths/minute)
30-60
25-40
20-30
12-20

Normal heart rates in children

Age
Newborn
< 2 years
2-10 years
>10 years

Heart rate
(beats/minute)
80-200
80-180
60-150
60-100

Neonatal blood pressure

based on birth weight

Lower limit of systolic blood pressure by age

Age
Newborn
< 1 years
1-10 years
> 10 years

Systolic blood pressure (mm

Hg)
60
70
70 + (age in years x 2)
90

Blood glucose

Bedside assessment
Infant are vulnerable to hypoglycemia
Hypoglycemia may result
severe/permanent neurologic disability

History and Physical Examination

History
Serial assessment of vital signs, mentation,
and perfusion
Fever (serious infection?), hypothermia
(sepsis?)
The lung fields auscultation (rales :
hypervolemia?)
Gallop rhythm (underlying heart disease,
hypervolemia)
Palpation of liver edge below the costal
margin (hypervolemia, cardiac failure?)
Purpuric or petechial rashes (infectious?)
Secondary survey (injuries?)

Management of shock
1.
2.
3.
4.
5.
6.

ABCs of life support

Vascular access
Fluid resuscitation
Inotropic-Vasoactive
Control acidosis
Monitoring, laboratory studies,
CXR
7. Treat the underlying cause

ABCs of life support

Open airway
Suction
High Concentration O2
Assist ventilation (as needed)
Control bleeding
Shock position
Keep warm

Fluid
resuscitation
Use isotonic
crystalloid solution (eg, lactated
Ringers solution or normal saline) or 5 %
albumine.
Fluid boluses, 20 mL per kg, severe : 40-60
ml/kg, max 200 ml/kg rapidly until the shock
is resolved (delivered in 5-10 minutes)
Observing for signs of fluid overload
(increased work of breathing, rales, gallop
rhythm, or hepatomegaly)
Use a glucose-containing solution to only treat
documented hypoglycemia
Correct hypocalcemia
Insufficient data to recommendation or
against using hypertonic saline for shock
associated with head injuries or hypovolemia

Inotropes-Vasoactive
Inotropes-Vasoactive agents is use if shock
requiring pharmacologic improvement of
cardiac contractility function or
decompensated shock refractory to volume
expansion alone

Inotropes/Vasoactive Agents
Dopamine

1-5 mcg/kg/min: dopaminergic; 5-15

mcg/kg/ min: more beta-1; 10-20
mcg/kg/min: more alpha-1

Dobutamine

2.5-15 mcg/kg/min; mostly beta-1,

some beta-2

Epinephrine

0.05-0.1 mcg/kg/ min: mostly beta-1,

some beta-2; >0.1 to 0.2 mcg/ kg/min:
alpha-1

Nor-epinephrine

0.05-0.2mcg/kg/ min; Use up to

1mcg/kg/min; only alpha and beta-1

Milrinone

50mcg/kg load then 0.375-0.75

mcg/kg/min; Phosphodiesterase
inhibitor; results in increased inotropy
and peripheral vasodilation (greater
effect on pulmonary vasculature)

Control acidosis

Metabolic acidosis may become evident as

childs condition worsen
Na Bic no longer routinely recommended
because the use of Na Bic may increase
intracellular acidosis
Fluid resuscitation, vasoactive infusion and
adequate ventilation/oxygenation are the
main management
Tromethamine /THAM given slowly (3-5
ml/kg) may use in extreme condition (i.e. pH
< 7)

Monitoring, lab studies, and CXR

Monitoring HR, BP continuously
Clinical evaluations/5 min until the patient is
stable
Urine output monitoring with an indwelling
catheter
Lab : ABG, serum electrolytes, glucose, Ca
levels, CBC, PT/PTT, blood type/cross match,
and culture
Evaluate ET tube position, heart size, and
pulmonary status by CXR

Treat the underlying cause

Trauma: ongoing bleeding may need to be
addressed surgically
Myocardial failure: inotropic medications
Sepsis: isolated and treat the infectious
organism with appropriate ABs