shock resident lecture
TRANSCRIPT
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PEDIATRICPEDIATRIC
SHOCKSHOCK20122012
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SHOCKSHOCK
Shock is a syndrome that resultsShock is a syndrome that results
from inadequate oxygen delivery tofrom inadequate oxygen delivery to
meet metabolic demandsmeet metabolic demands
Sequelae of shock are metabolicSequelae of shock are metabolic
acidosis, organ dysfunction andacidosis, organ dysfunction and
deathdeath
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OXY!"S#$$%Y
OXY!"&!'("&
S)O*+OX!" S#$$%Y -(.%S /O '!!/ OXY!"&!'("&
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OY!"&!%.!Y
*(&.(* O#/$#/ X (/!.(% OXY!" *O"/!"/
*ardiacOutut
(rterial oxygen content
)eart rate Stroke olume
$reload(fter load*ontractility
)emoglobinOxygen Saturation$artial ressure of oxygen dissolvelasma
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Factors afecting OxygenFactors afecting Oxygen
deliverydelivery Oxygenation(a gradient, &$, acidOxygenation(a gradient, &$, acid
base balance, /em, :lockersbase balance, /em, :lockers
Stroke volumeentricularStroke volumeentricularcomliance, *$, venous tone,comliance, *$, venous tone,
autonomic tone, metabolic milieu,autonomic tone, metabolic milieu,
afterload, conduction systemafterload, conduction system
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Types o S!oc"Types o S!oc"
)yovolemic )emorrhage, serum or lasma)yovolemic )emorrhage, serum or lasmalossloss
&istributive(nahylactic, "eurogenic, setic&istributive(nahylactic, "eurogenic, setic
*ardiogenic 'yocardial, dysrrythmia,*ardiogenic 'yocardial, dysrrythmia,*)&8duct deendant9*)&8duct deendant9 Obstructive$neumo, tamonade, dissectionObstructive$neumo, tamonade, dissection &issociative)eat, *O, cyanide, endocrine&issociative)eat, *O, cyanide, endocrine
; has )yovolemic shock secondary to; has )yovolemic shock secondary to)emorrhage)emorrhage
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Case #Case #
< year old girl ; =ith a history of variceal bleed< year old girl ; =ith a history of variceal bleedresents =ith ne= onset bleed4 O>!resonsive,resents =ith ne= onset bleed4 O>!resonsive,)15?, 5@, :$@@>A0, SatsA0, Sats26>@0>12>64 )b642C40@>26>@0>12>64 )b642
Dhat tye of shock is thisEDhat tye of shock is thisE)yovolemic Shock)yovolemic Shock Dhat is the very Frst thing you =ould like to doDhat is the very Frst thing you =ould like to do
for this atientEfor this atientE
OxygenOxygen .s this comensated or uncomensated shock.s this comensated or uncomensated shock
ho= does the body comensateEho= does the body comensateE
*omensated*omensated
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Stages o S!oc"Stages o S!oc"
*omensated ital organ function*omensated ital organ functionmaintained, normal :$maintained, normal :$
#ncomensated'arginal microvascular#ncomensated'arginal microvascular
erfusion4Organ and cellular functionerfusion4Organ and cellular functiondeteriorate4 )yotension develos4deteriorate4 )yotension develos4
.rreversible.rreversible
; has comensated shock because her; has comensated shock because herblood ressure is normalblood ressure is normal
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Co$pensatoryCo$pensatory
%ec!anis$s%ec!anis$s :arorecetors.n aortic arch and:arorecetors.n aortic arch and
carotid sinus, lo= '($ causecarotid sinus, lo= '($ cause
vasoconstriction, increases :$, *Ovasoconstriction, increases :$, *O
and )and )
*hemorecetors esond to cellular*hemorecetors esond to cellular
acidosis, results in vasoconstrictionacidosis, results in vasoconstriction
and resiratory stimulationand resiratory stimulation
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Co$pensatoryCo$pensatory
%ec!anis$s%ec!anis$s enin (ngiotensin &ecreased renalenin (ngiotensin &ecreased renal
erfusion leads to angiotensinerfusion leads to angiotensin
causing vasoconstriction andcausing vasoconstriction and
aldosterone causing salt and =ateraldosterone causing salt and =aterretentionsretentions
)umoral esonses*atecholamines)umoral esonses*atecholamines
(utotransfusioneabsortion of(utotransfusioneabsortion of
interstitial Guidinterstitial Guid
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R&'s Clinical presentationR&'s Clinical presentation
&iagnosis is based on exam focused on tissue&iagnosis is based on exam focused on tissueerfusionerfusion
"eurological-luctuating mental status"eurological-luctuating mental status Skin and extremities*ool, allor, mottling,Skin and extremities*ool, allor, mottling,
cyanosis, oor ca reFll, =eak ulses, =eakcyanosis, oor ca reFll, =eak ulses, =eakmuscle tonemuscle tone
*ardioulmonary)yernea, tachycardia*ardioulmonary)yernea, tachycardia enalScant, concentrated urineenalScant, concentrated urine
(bHect hyotension is a late and remorbid(bHect hyotension is a late and remorbidsign8 and is the Gag for uncomensated shock9sign8 and is the Gag for uncomensated shock9
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Hypovole$ic s!oc"Hypovole$ic s!oc"
*ommonest cause =orld=ide*ommonest cause =orld=ide
&ecreased blood volume, decreased&ecreased blood volume, decreased
reload, decreased stroke volumereload, decreased stroke volume
Signs of dehydrationtears, mucousSigns of dehydrationtears, mucous
membranes, skin tugormembranes, skin tugor
Site of Guid loss may be obvious orSite of Guid loss may be obvious orconcealed8liver, sleen, intracranial,concealed8liver, sleen, intracranial,
.9.9
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Oxygen()!at aOxygen()!at a
diference*diference*(rt Oxygen content3 )b x Sa02 x 1456(rt Oxygen content3 )b x Sa02 x 1456
7804005 x $a0297804005 x $a029
$a02 on 100B is arox A?0$a02 on 100B is arox A?0
$a02 on room air is arox 100$a02 on room air is arox 100
.f your )b is 1? this diIerence in $aO2.f your )b is 1? this diIerence in $aO2
does not make much diIerence if yourdoes not make much diIerence if your
)b is ? it makes all the diIerenceJ)b is ? it makes all the diIerenceJ
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R&'s %anage$entR&'s %anage$ent
.ncrease oxygen delivery, decrease oxygen.ncrease oxygen delivery, decrease oxygen
demanddemand
OxygenOxygen
-luid-luid :lood:lood
/emerature control/emerature control
*orrect metabolic abnormalities*orrect metabolic abnormalities .notroe if needed.notroe if needed
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+a,s+a,s
(:(: :lood sugar:lood sugar
!lectrolytes!lectrolytes
*:**:* $/>$//>-ibrinogen$/>$//>-ibrinogen
/ye and *ross/ye and *ross *ultures*ultures .maging.maging
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-ol.$e expansion-ol.$e expansion
OtimiKe ;Ls reload =ith "S or %OtimiKe ;Ls reload =ith "S or %
1020cc>kg q 210min4 ; is given 21020cc>kg q 210min4 ; is given 2
boluses4boluses4
; is given 2 units of blood4 )er; is given 2 units of blood4 )er
heart rate stabiliKes at @A4 :$heart rate stabiliKes at @A4 :$
112>@04112>@04
; is deemed stable and gets; is deemed stable and gets
sclerotheraysclerotheray
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R& At EndoscopyR& At Endoscopy
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Case /Case /
/" is a ? year old girl =ith a history of #./" is a ? year old girl =ith a history of #.symtoms 2 =eeks ago resents =ithsymtoms 2 =eeks ago resents =ithdecreased eIort tolerance, tachynea 4 O>!decreased eIort tolerance, tachynea 4 O>!)1l rales, no heart murmuron exam but a gallo is heard4on exam but a gallo is heard4
Dhat tye of shock is thisEDhat tye of shock is thisE
#ncomensated cardiogenic shock#ncomensated cardiogenic shock Dhat is the diagnosisE )o= do you manageDhat is the diagnosisE )o= do you manage
this atientEthis atientE
'yocarditis'yocarditis
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Diferentiating CardiogenicDiferentiating Cardiogenic
S!oc"S!oc" )istory)istory
$!enlarged liver, gallo, murmur,$!enlarged liver, gallo, murmur,
ralesrales
*hest X ray!nlarged heart,*hest X ray!nlarged heart,
ulmonary venous congestionulmonary venous congestion
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%yocarditis%yocarditis
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OY!"&!%.!Y
*(&.(* O#/$#/ X (/!.(% OXY!" *O"/!"/
*ardiacOutut
(rterial oxygen content
)eart rate Stroke olume
$reload(fter load*ontractility
)emoglobinOxygen Saturation$artial ressure of oxygen dissolvelasma
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%anaging T0%anaging T0
.ncreasing Oxygen suly.ncreasing Oxygen suly
Sulemental OxygenSulemental Oxygen
.mroving myocardial oututaltering.mroving myocardial oututaltering
reload, after load and contractilityreload, after load and contractility*orrect (nemia:lood*orrect (nemia:lood &ecreasing oxygen demand&ecreasing oxygen demand
*ontrol temerature*ontrol temerature
SedationSedation
educe myocardial =ork and thus oxygeneduce myocardial =ork and thus oxygenconsumtionconsumtion
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Fl.ids in CardiogenicFl.ids in Cardiogenic
S!oc"S!oc" ive small volume boluses of ?ive small volume boluses of ?
10ml>kg10ml>kg
/" has myocarditis and because of/" has myocarditis and because of
this she has diastolic dysfunctionthis she has diastolic dysfunction
giving her extra Guid may overloadgiving her extra Guid may overload
her heart4her heart4
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Ionotropes1CardiotonicsIonotropes1Cardiotonics
&oamine%o= dose increases renal and&oamine%o= dose increases renal and
slanchnic blood Go=, high dose increasesslanchnic blood Go=, high dose increases
) and S4) and S4
&obutamine .ncreases contractility, may&obutamine .ncreases contractility, may
reduce S, $4reduce S, $4
'ilrinone.notroy and venodilation4'ilrinone.notroy and venodilation4
.mrove contractility and decrease after.mrove contractility and decrease after
loadload
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Ionotropes1 CardiotonicsIonotropes1 Cardiotonics
!inehrine .ncreases ),S and!inehrine .ncreases ),S and
contractility4 !nd ointadequate :$,contractility4 !nd ointadequate :$,
accetable tachycardiaaccetable tachycardia
"oreinehrine040?140mcg>kg>min4 .ncreases"oreinehrine040?140mcg>kg>min4 .ncreases
S4S4
:e hesitant to use either of these drugs for /" as:e hesitant to use either of these drugs for /" as
they increase myocardial oxygen consumtionthey increase myocardial oxygen consumtion
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T0's Hospital Co.rseT0's Hospital Co.rse
10ml>kg bolus =ith normal saline10ml>kg bolus =ith normal saline
results in minimal elevation of bloodresults in minimal elevation of blood
ressureressure
Started on &oamine of ?mcg>kg>minStarted on &oamine of ?mcg>kg>minand 'ilrinone 04? mcg>kg>minand 'ilrinone 04? mcg>kg>min
Stable for transort to *ardiac .*#Stable for transort to *ardiac .*#
(ttemted intubation results in(ttemted intubation results incirculatory collase/" goes u oncirculatory collase/" goes u on
!*'O!*'O
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Ot!er ca.ses oOt!er ca.ses o
Cardiogenic S!oc"Cardiogenic S!oc" &ysrhythmia&ysrhythmia
.nfection.nfection
'etabolic'etabolic ObstructiveObstructive
&rugs&rugs
*ongenital heart disease*ongenital heart disease /rauma/rauma
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Case 2Case 2
6 year old boy S resents =ith 5 day h>o fever,6 year old boy S resents =ith 5 day h>o fever,malaise4 )e has a ast history of nehroticmalaise4 )e has a ast history of nehroticsyndrome4O>!'inimally resonsive,skin aearssyndrome4O>!'inimally resonsive,skin aearsGushed and =arm, and he has bounding ulses4 )Gushed and =arm, and he has bounding ulses4 )1C0 50 :$60 systolic, sats@@B41C0 50 :$60 systolic, sats@@B4
Dhat tye of shock does the atient haveDhat tye of shock does the atient have
#ncomensated distributive shock Darm setic shock#ncomensated distributive shock Darm setic shock Dhat medications could be used in the managementDhat medications could be used in the management
of this atientEof this atientE
-luid, antibiotics, ressors, steroids-luid, antibiotics, ressors, steroids
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Septic S!oc"Septic S!oc"
'ediator release both exogenous'ediator release both exogenous
and endogenous lead toand endogenous lead to
misdistribution of blood, imbalancemisdistribution of blood, imbalance
of oxygen suly and demand,of oxygen suly and demand,alterations in metabolism andalterations in metabolism and
cardiac dysfunctioncardiac dysfunction
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)ar$ S!oc")ar$ S!oc"
!arly comensated hyerdynamic!arly comensated hyerdynamic
state of setic shockstate of setic shock
Darm extremities, bounding ulses,Darm extremities, bounding ulses,
tachycardia, =ide ulse ressure,tachycardia, =ide ulse ressure,
decreased systemic vasculardecreased systemic vascular
resistance and increased cardiacresistance and increased cardiac
oututoutut Often =ith hyerglycemiaOften =ith hyerglycemia
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Cold S!oc"Cold S!oc"
%ate uncomensated stage of setic%ate uncomensated stage of setic
shock =ith dro in cardiac oututshock =ith dro in cardiac outut
and increased Sand increased S
*old and clammy skin, raid thready*old and clammy skin, raid thready
ulses, shallo= breathingulses, shallo= breathing
(ssociated metabolic acidosis,(ssociated metabolic acidosis,
hyoxia, coaguloathy,hyoxia, coaguloathy,
hyoglycemia, caillary leakhyoglycemia, caillary leak
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PA+S A+3ORITH%PA+S A+3ORITH%
11S/S/hour20ml>kg>boluses4hour20ml>kg>boluses4
*orrect hyoglycemia and*orrect hyoglycemia and
hyocalcemia4hyocalcemia4
(dminister 1(dminister 1ststdose of antibioticsdose of antibiotics
*onsider vasoressor dri and stress*onsider vasoressor dri and stress
dose hydrocortisonedose hydrocortisone &!/!'."! D)!/)! -%#.&&!/!'."! D)!/)! -%#.&
!S$O"S.!!S$O"S.!
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PA+S A+3ORITH%PA+S A+3ORITH%
.- "O/ -%#.& !S$O"S.!.- "O/ -%#.& !S$O"S.!
"ormotensiveStart &oamine"ormotensiveStart &oamine
)yotensive vasodilated8=arm shock9)yotensive vasodilated8=arm shock9"oreinehrine"oreinehrine
)yotensive vasoconstricted8cold)yotensive vasoconstricted8cold
shock9!inehrineshock9!inehrine!(%#(/! '.X!& !"O#S S(/,!(%#(/! '.X!& !"O#S S(/,
O(%MC0BO(%MC0B
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RS( Hospital Co.rseRS( Hospital Co.rse
100ml>kg of Guid is given, :$ imroves to100ml>kg of Guid is given, :$ imroves to
A0>50A0>50
Started on "oreinehrine dri follo=ingStarted on "oreinehrine dri follo=ing
=hich :$ imroves to systolic of @04=hich :$ imroves to systolic of @04 t .; laced ScO2C6Bt .; laced ScO2C6B
)ydrocortisone 2mg>kg1 dose given)ydrocortisone 2mg>kg1 dose given
Starts ancomycin and *eftriaxoneStarts ancomycin and *eftriaxone
'icrobiology calls to tell you there are ram'icrobiology calls to tell you there are ram
"eg rods on blood culture smear"eg rods on blood culture smear
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PA+S A+3ORITH%PA+S A+3ORITH%
ScvO2MC0B, %o= :$, =arm shock(dditionalScvO2MC0B, %o= :$, =arm shock(dditionalGuid4 "oreinehrine 7> asoressinGuid4 "oreinehrine 7> asoressin
ScvO2NC0B, normal :$, oor erfusionScvO2NC0B, normal :$, oor erfusion/ransfuse to )bM10g>dl4 *onsider milrinone>/ransfuse to )bM10g>dl4 *onsider milrinone>nitrorusside>dobutaminenitrorusside>dobutamine
ScvO2NC0B, lo= :$, oor erfusionScvO2NC0B, lo= :$, oor erfusion/ransfuse to )bM10g>dl4 *onsider/ransfuse to )bM10g>dl4 *onsidereinehrine or dobutamine 7noreinehrineeinehrine or dobutamine 7noreinehrine
(&!"(% ."S#--.*.!"*Y(&!"(% ."S#--.*.!"*Y
)ydrocrtisone 2mg>kg)ydrocrtisone 2mg>kg
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Ho4 $.c! 5.id is toHo4 $.c! 5.id is to
$.c!6$.c!6 -luids in early setic shock *arcillo,-luids in early setic shock *arcillo,;('( 1kg in Frst hour5 'ore than 60cc>kg in Frst hour
"O &.--!!"*! ." (&S"O &.--!!"*! ." (&S:!/D!!" O#$S:!/D!!" O#$S
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Concl.sionsConcl.sions
ecognise shock quicklytachycardiaecognise shock quicklytachycardia
is the Frst sign, hyotension is lateis the Frst sign, hyotension is late
ain access quicklyif needed use .O4ain access quicklyif needed use .O4
$. better than a central line$. better than a central line
.f atient is not resonding the =ay.f atient is not resonding the =ay
you think broaden your diIerential,you think broaden your diIerential,
think about other tyes of shock4think about other tyes of shock4