thanks to all first responders, - university of arizona
TRANSCRIPT
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Thanks to all first responders, hospital staff , TPD and all who organized this conference.
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Pediatric Shock …………….. So What?
Michael Karadsheh, MD
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n Before I start, I got something important to say…….– I was told to be accurate, to the point and brief.– So, I promise I will be as brief as possible ….no
matter how long it takes
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Pediatric Shock in Review!
Agenda:- Shock.
- Definition and classification.- Oxygen delivery and consumption.- Treatment, the simple and the complex.
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Pediatric Shock in Review!
Shock:– Definition: An acute complex state of
circulatory dysfunction involving cellular oxygen deficiency.
– A balance between oxygen demand and supply.
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Pediatric Shock in Review!
Oxygen delivery= CO X Oxygen content
Heart rate
Stroke Volume Hb x1.39 X SaO2 +0.003 X PaO2
preload
afterloadcontractility
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Pediatric Shock in Review!
n Oxygen delivery vs consumption
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Pediatric Shock in Review!
n Classification of Shock:– Hypovolemic.– Septic.– Cardiogenic.– Obstructive– Endocrine
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Pediatric Shock in Review!
n Assessment:– History:
• Illness.– Intake and output
• Medication.• Cardiac history• Trauma• Travel
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Pediatric Shock in Review!
n Assessment:– BCA:
• Respiratory effort, symmetry• Oxygenation.• Establish access.
– Pulses:• Femoral, Brachial, Radial.
– Blood pressure:• Upper and lower
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Pediatric Shock in Review!
n Chest Xray.n Lab:
– CBC.– Electrolyte, accucheck– VBG/ABG.– Lactate– Blood culture– Monitor input and output.
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Pediatric Shock in Review!
n Hypovolemic shock:– It is the most common type of shock in
pediatrics population.– Gastroenteritis is the most common cause.
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Pediatric Shock in Review!
n Hypovolemic shock:– Signs of dehydration:
• Dry mouth.• Decrease urine output.• Lethargic• Tachycardia and hypotensive.• Increase capillary refill.
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Pediatric Shock in Review!
n Hypovolemic shock:– Treatment:
• Fluid, fluid and fluid– NS, LR.
• 20 ml/kg push up to 60 ml/kg.– No dextrose in fluid and avoid ½ or ¼ normal saline.– Blood when indicated.
• Continue resuscitation till restore blood pressure.
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Pediatric Shock in Review!
n Sepsis and Septic Shock:– Evidence of infection plus life threatening
organ dysfunction with acute changes.
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Pediatric Shock in Review!
n Septic Shock:– Stages:
• Compensatory.– Blood pressure can be normal initially.– Oxygen saturation can be normal.
• Uncompensatory• Irreversible.
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Pediatric Shock in Review!
Septic Shock:– Classification:
• Cold or Warm septic shock.• Fluid refractory/Dopamine.• Catecholamine resistant shock.• Refractory shock
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n Septic Shock:– Sepsis with fluid unresponsiveness hypotension,
serum lactate more than 2.0, and the need for pressors to maintain higher MAP.
Pediatric Shock in Review!
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Pediatric Shock in Review!
n Triad in Septic shock ( SIRS):– Hypothermia and Hyperthermia.– Altered mental status– Peripheral vasodilatation.
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Pediatric Shock in Review!
n Septic Shock:– Early resuscitation and reversal of septic shock
by community ER physician and first line responders are associated with improved outcome.
– Early resuscitation: normalization of blood pressure and capillary refill.
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Pediatric Shock in Review!
n Septic Shock:– Early reversal of shock ( median time=75 min)
associated with 96% survival and a 9 fold increased odds of survival.
– For each hour of persistent shock and for each hour of delay in resuscitation, the odds of mortality increased by 2 fold and 1.5 fold respectively.
– Non-survivors received more mechanical ventilation and pressors support than survivors.
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Pediatric Shock in Review!
Recommendation for Pediatric septic shock by the ACCM-PALS:– 0-5 minutes:
• Recognize signs of poor perfusion• Recognize and maintain airway:
– 100% oxygen.– Early intubation if indicated.
• Establish IV access
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Pediatric Shock in Review!
n Recommendation for Pediatric septic shock by the ACCM-PALS:– 5- 15 min:
• Push fluid 20 ml/kg up to 60 ml/kg.• Maintain Hb more than 10 gm/dl.• FFP to correct PT and PTT.• Correct hypoglycemia and hypocalcemia.
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Pediatric Shock in Review!
n Treatment of shock ( 0-60 minutes)– Immediate consideration of antibiotics.– Do not delay because of delay in obtaining
cultures.
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Pediatric Shock in Review!
Septic Shock:– Patients who don't respond rapidly to initial
fluid boluses, or with insufficient physiologic reserve should be considered for invasive hemodynamic monitoring:
• Central line.– CVP-MAP .
• PA line
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Pediatric Shock in Review!
n Recommendation for Pediatric septic shock by the ACCM-PALS: – Vasopressor therapy:
• Dopamine first line of therapy.– if fluid refractory and dopamine resistant:
• Epinephrine for cold, and NE for warm septic shock.– Catecholamine resistant:
• start hydrocortisone( 50mg/m2/d divided Q 6 hrs).
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Pediatric Shock in Review!
n Recommendation for Pediatric septic shock by the ACCM-PALS:– ECMO: Extra corporeal membrane
oxygenator.• VV.• VA.
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Pediatric Shock in Review!
n Other types:– Obstructive shock
• Pneumothorax• Pericardial tamponade
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Pediatric Shock in Review!
n Other types:– Cardiogenic shock
• Newborn think of:– Congenital heart defect– Congenital adrenal hyperplasia
– Endocrine shock• Medication infusion
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Pediatric Shock in Review!
Conclusion:– Early recognition and aggressive resuscitation
of pediatric septic shock by community physicians can save lives.
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n Thanks again to all of you as first responders for what you are doing and have done especially in this past year and during the tough time.
God Bless