Shock in Children

Summary of Case presentation 1

PC.
• Fever X6/7
• Cough X6/7
• DIB X2/7
HPC
9 months old infant, presented with a history of wet cough fever for 6 days.
Fever were relieved by intermittent doses of paracetamaol syrup. difficult in
breathing for two days, failure to breastfeed for 1 day. No any body swelling.
ROS.
GIT. Vomiting for 2 days, post prandial, non bilious, non projectile. Diarrhoea for 1
day, three loose motions
OTHER SYSTEMS. Unremarkable
IMMNZN. Completed series of vaccination with measles 2 weeks before admission.
O/E
Very sick child, in respiratory distress with subcostal recession, nasal flaring,
respiratory rate of 65bpm, SPO2 85%. Child was lethargic, capillary refill >3S,
cold extremities, no pallour, no jaundice, heart rate of 150bpm, temperature
38.4 degrees celicious. RBS 5.3 mmol/dl
On chest auscultation, reduced air entry in both lungs, bronchial breathing,
widespread crepitations.
DX. Bronchopneumonia with septic shock.
MGT.
ampicillin and gentamicin
Iv paracetamol
Oxygen therapy
Iv fluids
 Case presentation 2
P/C
• Diarrhea- 3/12
• Persistent vomiting- 4/7
HPC
1 year 4 months old child was well until 3 months ago when
she developed greenish mucoid loose motions that were non
bloody and non foul smelling about 5 times daily. Mother
reports poor weight gain since the start of the illness
Also reports projectile non- bilious vomiting for 4 days. The
child vomits everything. Associated with a low grade fever but
no l.o.c or convulsions.
FSH
Last born of 8 who stays with her grandmother because the
parents separated and the mother went to work. No stable
source of income for the grand mother.
O/E
Very sick looking wasted child, not in obvious respiratory
distress. Child was lethargic, had cold extremities, cap ref 4
seconds, skin pinch went back very slowly, Pulse was weak
and fast at 128 beats per minute. Afebrile at 36.1 , no
jaudice, no pallor, no edema. respiratory rate 25 breaths
per minute.
Nutrition status assessment:
The child had a weight of 6.0kg, length of
80.1cm, weight for height (WH) Z score <-3 SD,
mid upper arm circumference of 10.8cm
Diagnosis
1 year 6 months old child with shock in severe
acute non edematous malnutrition.
Management:
• Oxygen therapy 1 litre per minute
• 60mls of D10 I.V bolus
• 90 mls of half strength darrows with D5
• I.V ampicillin 300mg for 2 days
• I.V Gentamycin 45mg for 7 days
 Shock
• Complex pathophysiologic state characterised by
significant reduction in tissue perfusion resulting in
decreased tissue oxygen delivery

• Prolonged oxygen deprivation leads to generalised

hypoxia and disruption of critical biochemical
processes.
 Shock
eventually results in…
• Cell membrane ion pump dysfunction
• Intracellular edema
• Inadequate regulation of intracellular pH
• Cell death

These abnormalities manifest clinically by

- End-organ damage
- Failure of multiple organ systems
- Death
 Physiology
• Global tissue perfusion is determined by
- systemic vascular resistance (SVR)
- cardiac output (CO)
• SVR- related directly to vessel length and blood
viscosity, and inversely to vessel diameter
• Vessel length and blood viscosity are relatively fixed,
vessel diameter (a function of many autonomic and
endothelial factors) is dynamic
 Physiology
• CO is the product of heart rate and stroke volume
• Stroke volume is determined by
- Preload (ventricular filling)
- Myocardial contractility (pump function)
• SVR and CO distinguish among the different types of
shock
 Classification
• Three broad mechanisms of shock:

- Hypovolemic

- Distributive/streptic

- Cardiogenic

• Each type is characterised by one physiologic

derangement
 Hypovolemic shock
• Most common type of shock in children

• Major cause in developing countries is diarrhea.

• Results from decreased preload

• Two broad etiological categories : Fluid loss and

hemorrhage (Trauma and intestinal haemorrhage)
 Distributive shock
• Results from a decrease in SVR
• Abnormal distribution of blood flow within the
microcirculation and inadequate tissue perfusion
• Can lead to functional hypovolemia, with a
decreased preload
• Generally associated with a normal or increased
cardiac output
• Etiology: Sepsis (septic shock)- most common,
anaphylaxis, injury to CNS (neurogenic shock), Burn
injuries
 Cardiogenic shock
• Results from pump failure (decreased systolic
function, depressed cardiac output)
• Mechanisms: Four general categories
- Cardiomyopathies
- Arrythmias
- Mechanical abnormalities
- Obstructive disorders
• Compensatory mechanisms triggered by
cardiogenic shock of any cause can further impair
cardiac function
 History
• Presenting complaints
• Vomiting and diarrhea
• Food and medicine allergies
• Recent changes in medication
• Potential acute/chronic drug intoxication
• Preexisting diseases
• Immune suppression
• Hypercoagulable conditions
• Trauma
 Common features
• Tachycardia
• Hypotension
• Skin and mucousal changes
• Impaired mental status
• Oliguria
• Lactic acidosis
 Physical exam
• Rapid, efficient, uncover the features/consequences
and most likely causes of shock
• Skin: Cold clammy or warm hyperemic skin, rashes,
petechiae, purpura, urticaria, cellulitis, infected
vascular access catheters
• HEENT: jaundice, dry mucous membranes, pinpoint
pupils, dilated and fixed pupils, nystagmus, bulging
or sunken fontanelle
• Neck: Jugular venous distension, adenopathy,
meningeal irritation
 Physical exam
• Resp: Tachypnoea, shallow breaths, deep sighing
breaths, crackles, wheeze, stridor, bronchial or
absent breath sounds, pleural friction rub
• CVS: tachy/bradycardia, irregular heart rhythm,
gallop, diffuse PMI, right/left ventricular heave,
murmurs, distant heart sounds, pericardial rub,
pulsus paradoxus (Pulse is weaker/disappears on inspiration),
Kussmaul sign (JVP rises on inspiraton)
• Neuro: BCS, GCS, confusion, seizures, paresis, focal
deficits,
 Physical exam
• Extremeties: Weak pulse, delayed capillary refill,
cyanosis, edema, unequal intensity of pulses,
disparity of BP among extremeties,
• Abdomen: Tenseness, distension, tenderness,
peritoneal signs, absence of (or high-pitched) bowel
sounds, pulsatile masses, hepatosplenomegaly,
ascites,
• Rectal exam: Decreased tone, bright red blood,
melena,
 Lab Evaluation
To identify potential • Cardiac enzymes
causes of shock and early • Toxicology screen
signs of organ failure • Chest radiograph
• Arterial Blood Gases • Abdominal radiograph
• FBC • ECG
• Basic chemistry tests • Urinalysis
• Liver function tests
• Fibrinogen and fibrin split
products
• Amylase and lipase
 Management
• Shock is a paediatric emergency

• Management is goal directed

• Starts as soon as Shock is detected

• Fluid therapy is an important component

• Specific therapy depends on cause/type

 Therapeutic goals/targets
• Normal mental status
• Normal blood pressure for age
• Normal or threshold heart rate for age
• Normal and equal central and peripheral pulses
• Warm extremities with capillary refill of 2 seconds or less
• Urine output greater than 1 mL/kg/h
• Normal serum glucose levels
• Normal serum ionized calcium levels
• Decreasing serum lactate levels
 Goal directed therapy: 5 – 15 min
• Airway, Breathing, Circulation
• 100% oxygen to all
• Recognise and treat life threatening conditions
• Establish vascular access
• Administer a bolus of isotonic crystalloid
• Anaphylaxis: give IM epinephrine, hydrocortisone,
dyphenydramine
• Diagnostic studies: glucose, CBC, electrolytes, blood
cultures, Blood gases, blood type and crossmatch
• Monitor physiologic indicators and pulse-oximetry
 Goal directed therapy: 15 – 30 min
• Identify and treat abnormalities in blood glucose, calcium,
electrolytes
• Consider vasoactive drug therapy (dopamine, dobutamine,
nor/epinephrine) in children with cardiogenic shock, not
responding to fluid bolus
• Administer appropriate antibiotics if septic shock is
suspected
• Insert a urinary catheter to monitor urine output
• 20ml/kg boluses of isotonic fluid may be repeated to a total
of 60ml/kg over the first 30min, except in cardiogenic shock
and DKA
 Goal directed therapy: 30 – 60 min
• Re-evaluate presumed cause of shock
• For possible hypovolemic shock, re-evaluate
estimate of fluid losses, continue fluid replacement,
consider colloid
• For possible septic shock not responsive to fluid
therapy, consider vaso-active drug therapy
• For hemorrhagic shock, consider blood products
 Fluid administration
• Fluid therapy begins with isotonic crystalloid e.g.
Normal saline, lactated Ringer’s solution
• Each 20ml/kg bolus is given over 5 – 10 min
• In DKA, give careful slow bolus (10ml/kg over 1
hour) to avoid cerebral edema. Max 2 boluses
• In suspected cardiogenic shock, hypovolaemic
patients should receive 5 – 10 ml/kg over 10 – 20
min
 Intravenous fluids to a child in
shock without severe malnutrition
• Check that the child is not severely
malnourished, as the fluid volume and rate are
different.
• Insert an IV line (and draw blood for emergency
laboratory investigations).
• Attach Ringer’s lactate or normal saline; make
sure the infusion is running well.
• Infuse 20 ml/kg as rapidly as possible.
 Reassess the child after the appropriate
volume has run in.
Reassess after first infusion:
• If no improvement, repeat 10–20 ml/kg as
rapidly as possible.
• If bleeding, give blood at 20 ml/kg over 30
min, and observe closely.
Reassess After Second infusion:
 Reassess After Second infusion:

• If no improvement with signs of dehydration

(as in profuse diarrhoea or cholera), repeat 20
ml/kg of Ringer’s lactate or normal saline.
• If no improvement, with suspected septic
shock, repeat 20 ml/kg and consider
adrenaline or dopamine if available
• If no improvement, you should have
established a provisional diagnosis by now and
manage accordingly.
• After improvement at any stage (pulse volume
increases, heart rate slows, blood pressure
increases by 10% or normalizes, faster capillary
refill < 2 s), re-classify as in plan A, B or C
• Note: In children with suspected malaria or
anaemia with shock, rapid fluid infusion must
be administered cautiously, or blood transfusion
should be given in severe anaemia instead.
 Intravenous fluids to a child in
shock with severe malnutrition
• Insert an IV line (and draw blood for emergency laboratory
investigations).
• Weigh the child (or estimate the weight) to calculate the
volume of fluid to be given.
• Give IV fluid at 15 ml/kg over 1 h. Use one of the following
solutions according to availability:
– Ringer’s lactate with 5% glucose (dextrose);
– Half-strength Darrow’s solution with 5% glucose (dextrose);
– 0.45% NaCl plus 5% glucose (dextrose).
• Measure the pulse rate and volume and breathing rate at
the start and every 5–10 min.
 Cont’d
If there are signs of improvement (pulse rate
falls, pulse volume increases or respiratory
rate falls) and no evidence of pulmonary
oedema
– repeat IV infusion at 15 ml/kg over 1 h; then
– switch to oral or nasogastric rehydration with
ReSoMal at 10 ml/kg per h up to 10 hours.
– initiate re-feeding with starter F-75
 Cont’d
• If the child fails to improve after two IV boluses of
15 ml/kg,
– give maintenance IV fluid (4 ml/kg per h) while
waiting for blood;
– when blood is available, transfuse fresh whole
blood at 10 ml/kg slowly over 3 h (use packed
cells if the child is in cardiac failure); then
– initiate re-feeding with starter F-75 ;
– start IV antibiotic treatment
 Cont’d
• If the child deteriorates during IV rehydration
(breathing rate increases by 5/min and pulse
rate increases by 15/min, liver enlarges, fine
crackles throughout lung fields, jugular venous
pressure increases, galloping heart rhythm
develops)
• stop the infusion, because IV fluid can worsen
the child’s condition by inducing pulmonary
oedema.
 Before and after each fluid bolus..
Check:
• Quality of central and peripheral pulses
• Respiratory rate and pattern
• Skin perfusion (temp, capillary refill)
• Mental status
• Auscultation of lung and heart sounds
• Liver for hepatomegaly
• Urine output
 Pitfalls in management
• Failure to recognize nonspecific signs of
compensated shock (e.g. unexplained tachycardia,
abnormal mental status, or poor skin perfusion)

• Inadequate monitoring of response to treatment

• Inappropriate volume for fluid resuscitation

• Failure to reconsider possible causes of shock for
children are getting worse or not improving