pediatric shcok mgt

1. PEDIATRICS SHOCK MANAGMENT
Presenter Anteneh Tafere(R2)
Moderator, Dr. Muluwork Tefera (pediatrics
emergency and critical care specialist)
21/4/2022 1

2. Outline
• Definition
• Epidemiology
• Pathophysiology
• Classification
• Management
• Prognosis
• reference
21/4/2022 2

3. Definition
• Acute process characterized by the body's inability to
deliver adequate oxygen to meet the metabolic
demands of vital organs and tissues
• Insufficient oxygen at the tissue level is unable to
support normal aerobic cellular metabolism
• Resulting in a shift to less efficient anaerobic
metabolism
21/4/2022 3

4. Epidemiology
• Shock occurs in approximately 2% of all hospitalized
infants, children, and adults in developed countries
• Mortality rate varies substantially depending on the
etiology and clinical circumstances
21/4/2022 4

5. • Of patient who do not survive most do not die in the
acute hypotensive phase of shock but rather as a
result of associated complication and MODS
• MODS is defined as any alteration of organ function
that require support for maintenance
21/4/2022 5

6. Pathophysiology
• An initial insult triggers shock, leading to inadequate
oxygen delivery to organs and tissues
• Compensatory mechanisms attempt to maintain blood
pressure by increasing cardiac output and systemic
vascular resistance
21/4/2022 6

7. • The body also attempts to optimize oxygen delivery to
the tissues by increasing oxygen extraction and
redistributing blood flow to the brain, heart, and
kidneys at the expense of the skin and gastrointestinal
tract
21/4/2022
7

8. Con’d
• In the early phases of shock, multiple compensatory
physiologic mechanisms act to maintain BP and
preserve tissue perfusion and oxygen delivery
-Cardiovascular effect Increases in heart rate, stroke
volume, and vascular smooth muscle tone w/c are
regulated through sympathetic nervous system and
neuro humeral
21/4/2022 8

9. Con’d
- Respiratory compensation involves Greater carbon
dioxide elimination in response to metabolic acidosis
and increased CO2 production for poor tissue
perfusion
- Renal excretion of hydrogen ions and retention of
bicarbonate
21/4/2022 9

10. Con’d
• Despite this compensatory mechanism, the underling
shock and host response lead to vascular endothelial
cell injury and significant leakage of intravascular fluid
into interstitial extracellular space
• Another aspect of initial pathophysiology of shock is
the impact on cardiac output response
21/4/2022 10

11. b
Sequence of pathophysiologic events in clinical shock states
21/4/2022 11

12. 21/4/2022 12

13. • Early or Compensated Shock
-Tachycardia, mild tachypnea, slightly delayed capillary refill (> 2 to 3
seconds), orthostatic changes in BP or pulse, and mild irritability
• Late or Uncompensated Shock
-Early compensatory mechanisms are not enough to meet the metabolic
demands of the tissue
-The child shows signs of brain, kidney, and cardiovascular compromise
21/4/2022 13

14. Types of shock
• Hypovolumic shock
• Septic shock
• Cardiogenic shock
• Obstructive shock
• Distributive shock
21/4/2022 14

15. Case 1
• A 2 years old toddler presented with watery diarrhea w/c is non bloody
of 5x per day of 3 days duration and non projectile non bilus vomiting of
5x ,today patient unable to wake for feeding no fever, abdominal pain
but has decrease UOP
PE lethargic BP 50/30 PR 200 weak Temp 37
capillary refill > 5sec ,mottled ,dry buccal mucosa
• Is he in a shock?
• What type?
• Compensated or uncompensated?
• What are your intervention?
21/4/2022 15

16. Hypovolemic shock
• The most common cause of shock in children worldwide
• Inadequate tissue perfusion from decreased intravascular
volume as the result of fluid loss and/or inadequate fluid
intake
• Potential Etiology
-Vomiting and/or diarrhea, Osmotic diuresis, Capillary leak,
Hemorrhage, Inadequate fluid intake, Insensible losses
21/4/2022 16

17. • Clinical feature
- initial presentation orthostatic hypotension, dry
buccal mucosa ,poor skin turger and decreased UOP
- depending on degree of dehydration may present
with either normal or cool extremity
- once hypotension develop CVS dysfunction and
cardiac arrest can occur in minutes
21/4/2022 17

18. Timing
Compensated
Hypotensive
Cardiac Arrest
Possibly Hours
Potentially Minutes

19. Managment
• Airway and breathing
-Supplemental oxygen with an initial inspired
concentration of 100 percent
-Early positive pressure ventilation and intubation
should be performed in patients with airway
compromise or impending respiratory failure
21/4/2022 19

20. Con’d
• Control of hemorrhage
-Direct manual pressure to control bleeding
-sharp forceps body at site of bleeding or an
amputation
-compression at the nears vascular pressure points
-Suturing, surgical staples, or scalp clips
21/4/2022 20

21. Con’d
-Blood pressure tourniquet or Penrose drain
tourniquet
-reduction and splinting of long bone fracture
-Place a pelvic stabilization device over the greater
trochanter for suspected pelvic fracture
21/4/2022 21

22. Con’d
• Vascular access
-Adequate vascular access must be obtained for rapid
infusion of fluid
- Two peripheral intravenous catheters , that can be
reliably placed typically suffice
-Intraosseous cannulation should be performed if IV
access cannot be established quickly
21/4/2022 22

23. Con’d
• Fluid resuscitation
-goal of fluid therapy is rapid restoration of intravascular
volume
-Children with hypovolemic shock should receive isotonic
crystalloid 20 mL/kg per bolus over 5 to 10 min
-Repeated, as needed, up to three times with in the first 30 –
60 minutes
-Blood transfusion in patients with hypovolemic shock from
hemorrhage may be required
21/4/2022 23

24. Con’d
-Packed red blood cells should be given at 10 mL per
kg over 1 to 2 hours to maintain a hemoglobin of 10 g
per dL
-Abnormalities in blood glucose and electrolyte
measurements should be identified and treatment
initiated
21/4/2022 24

25. 21/4/2022 25

26. 21/4/2022 26

27. 21/4/2022 27

28. Case 2
• A 4 yreas old child presented with foul smell diarrhea of 1 days
duration 5-6 x a day associated with this he has intermittent
abdominal pain and non projectile non bilus vomiting 2 episode a day
,decrease urine out put
PE lethargic BP 60/40 PR 162 week RR 44 Tem 38,9
capillary refill > 4sec
Anthropometry unaffected
at emergency department resuscitated with NS 20 ml/kg 3x re
assement show no change
What are your next step in the management?
21/4/2022 28

29. Septic shock
• SIRS - at least 2 of the following findings, 1 of which
must be abnormal temperature or leukocyte count
• (i) hyper- or hypothermia
• (ii) tachycardia for age
• (iii) tachypnea
• (iv) Leukocyte count elevated or depressed for age
21/4/2022 29

30. • Sepsis - SIRS plus a suspected or proven infection
• Severe Sepsis - sepsis plus two or more organ
dysfunctions
• Septic Shock - Sepsis plus cardiovascular organ
dysfunction
• Etiology
-Could be bacterial, viral , fungal infections
21/4/2022 30

31. • Clinical feature
- initial sign and symptom of sepsis include alteration
in temp regulation, tachycardia and tachypnea
- in the early stage ( hyper dynamic phase, low
SVR,warm shock)
- as septic shock progress cardiac out put fall lead to
compensatory (high SVR and cold shock)
21/4/2022 31

32. Management
• Airway and breathing
• Treat hypoglycemia and hypocalcaemia
• Intravenous fluid therapy
-Initial therapy should begin with a bolus of
20 mL/kg of isotonic crystalloid solution, patients may
require volumes of 60 -100 mL/kg or more in the first
hour
21/4/2022 32

33. • Initial antimicrobial therapy
- Should be initiated immediately after obtaining appropriate
cultures within one hour of presentation
-Each hour delay in antibiotic administration has been
associated with an approximately 8 percent increase in
mortality
-Choice of antimicrobials can be complex and should consider
the child's age, history, co morbidities, clinical syndrome,
Gram stain data, and local resistance patterns
21/4/2022 33

34. Con’d
-Coverage for enteric organisms should be added whenever
clinical features suggest GU and/or gastrointestinal GI
sources
-Treatment for Pseudomonas species should be included
for children who are immunosuppressed
-Listeria monocytogenes and herpes simplex virus are
important pathogens in infants ≤28 days of age
-Ongoing antimicrobial therapy should be modified based
upon culture results, including antimicrobial susceptibility
and the patient’s clinical course
21/4/2022 34

35. Vasoactive medication
21/4/2022 35

36. 21/4/2022 36

37. Fluid refractory shock(15-60 min)
• continue fluid resuscitation
• initiate vasopressor then titrate to correct hypotension
• normotensive shock dopamine 2-20mcg/kg/min, if poor
perfusion continue dobutamine 2-20mcg/kg/min
• warm shock (bounding pulse, rapid capillary refill)
norepinephrine
• cold shock (cold extremity, narrow pulse pressure, slow
capillary refill) epinephrine
21/4/2022 37

38. Shock persist after vasopresor initiation
(60min)
• SVO2<70% cold shock ,transfuse if hg<10,optimize arterial oxygenation,
ventilation, epinephrine
• SVO2<70% normal Bp but poor perfusion, transfuse if hg< 10, consider
• SVO2 >70% warm shock norepinephrine 0.1-2mcg/kg/min iv/io titrate to
desired effect; consider vassopressin 0.2 -2mcg/kg/min and titrate to
desired effect
21/4/2022 38

39. Fluid and catecholamine refractory shock
• Hydrocortisone in stress doses (50mg/m 2 /day or
2 mg/kg per day, intermittent or continuous infusion is
suggested
• Should be discontinued when the patient becomes
hemodynamically stable and no longer requires
vasoactive medication administration
21/4/2022 39

40. • Extracorporeal Membrane Oxygenation
- Consider ECMO for refractory pediatric septic shock
and respiratory failure
• Blood Products and Plasma Therapies
-During resuscitation of Low superior vena cava oxygen
saturation shock (<70%), hemoglobin Levels of 10 g/dL
are targeted
21/4/2022 40

41. -After stabilization and recovery from shock and
hypoxemia, a lower target (>7.0 g/dL) can be
considered reasonable
-Platelet transfusion
-FFP transfused in patient with increased PT,PTT,INR
21/4/2022 41

42. Therapeutic end point
• Heart rate normal for age
• Capillary refill<2sec
• Normal pulse quality
• Warm extremity
• Blood pressure normal for age
• UOP > 1ml/kg/hr
21/4/2022 42

43. • Normal mental status
• CVP>8MMHg
• SvO2>70%
• Decreasing lactate
21/4/2022 43

44. Case 3
• This is 10 yrs old a known cardiac patient (CRVHD,S.MS)
on follow up for last 4 yr and taking lasix and
spironolactne but discontinued the drug for last 1 week
currently presented with worsening of sob and non
projectile vomiting 2 episode for a day
PE GA ASL in RD
BP 70/50 PR 160 week RR 48 Tem 36.7
o2 85 %
Capillary refill> 3 sec
21/4/2022 44

45. Con’d
Anthropometry-moderate wasting
RS-flaring of ala nase, sc/ic retraction
- bilateral rales
CVS- JVP is raised
-feeble peripheral pulse
-active and bulged precodium
- grade 2 mid diastolic murmur at the apex
Abdomen- hepatomegaly of 4cm BLCM,TLS is 12 cmCNS- irritable
What type of shock?
How do you intervene?
21/4/2022 45

46. Cardiogenic shock
• Decrease cardiac out put and evidence tissue hypoxia
with adequate circulation
• Cardiac pump failure secondary to Poor myocardial
function
• CHD, cardiomyopathy, ischemia, arrhythmia,
RHD(severe regurgitation and stenosis) postoperative
complications of cardiac surgery and metabolic
derangements
21/4/2022 46

47. • Cardiogenic – Decreased cardiac contractility caused
by conditions such as primary myocardial injury,
arrhythmias, cardiomyopathy, myocarditis, congenital
heart disease with heart failure, sepsis, or poisoning
21/4/2022 47

48. • Cardiogenic shock — Cardiogenic shock results from pump failure, manifested physiologically as decreased
systolic function and depressed cardiac output [10,11]. Cardiogenic shock is uncommon among children
(table 2), as compared with adults, among whom ischemic heart disease is the major cause.
• Cardiac causes may result from inadequate contractility or excessively fast or slow rhythms:
• ●Cardiomyopathies – Primary myocardial injury is an uncommon cause of shock in children. Causes of
myopathic pump failure include familial, infectious, infiltrative, and idiopathic cardiomyopathies. Prolonged
ischemia, cardiopulmonary bypass, and the myocardial depression of late sepsis all can contribute to
secondary myocardial dysfunction.
• ●Arrhythmias – Structural heart disease, drug intoxications, and hypothermia are leading causes of
arrhythmia in children. Both atrial and ventricular arrhythmias can cause cardiogenic shock.
21/4/2022 48

49. • •Ventricular fibrillation and pulseless ventricular tachycardia abolish cardiac
output, while diminished ventricular filling time during ventricular tachycardia
decreases preload and stroke volume substantially. (See "Management and
evaluation of wide QRS complex tachycardia in children".)
• •Prolonged unrecognized supraventricular tachycardia (as can occur with the
initial presentation for infants) can decrease cardiac output. (See "Clinical
features and diagnosis of supraventricular tachycardia in children".)
• •Bradyarrhythmias and complete heart block can result in shock caused by
chronotropic (heart rate) insufficiency, independent of stroke volume. (See
"Bradycardia in children".)
21/4/2022 49

50. Blunt cardiac injury
• Myocardial contusion
• Traumatic aneurysm
• Traumatic septal defect
• Chamber rupture
• Valvular rupture
21/4/2022 50

51. • Congenital heart disease
• Pulmonary hypotension
• Severe heart failure secondary to congenital heart
disease
• Postoperative cardiac surgery
21/4/2022 51

52. Drug toxicity
• Beta blockers
• Barbiturates
• Chemotherapeutic agents
• Calcium channel blockers
• Radiation
21/4/2022 52

53. • Metabolic derangements
• Acidosis
• Hyperkalemia
• Hypocalcemia
• Congenital organic acidemias
• Late septic shock
• Hypoxic or anoxic/ischemic injury
• Hypothermia
• Viral myocarditis
• Cardiomyopathies
• Dilated cardiomyopathies
• Infiltrative cardiomyopathies
• Mucopoylsaccharidosis
• Glycogen storage diseases
• Ischemic heart disease
• Anomalous left coronary artery
• Kawasaki disease
• Myocardial infarction
• Thyrotoxicosis
• Pheochromocytoma
21/4/2022 53

54. • Mortality exceeds 50% and management is focused on
a rapid diagnosis of cardiogenic shock, restoration of
coronary blood flow through early revascularization,
complication management, and maintenance of end-
organ homeostasis. Besides revascularization,
inotropes and vasodilators are potent medical
therapies to assist the failing heart.
21/4/2022 54

55. • Cardiogenic shock — A history of heart disease, an abnormal cardiac examination, and/or worsening clinical condition with fluid
resuscitation are suggestive of cardiogenic shock. Additional findings include tachycardia out of proportion to fever or respiratory
distress, cyanosis unresponsive to oxygen, raised jugular venous pulsations, and absent femoral pulses. Cardiogenic shock is less
common than other forms of shock in children. Early consultation with a pediatric cardiologist or intensivist is recommended. (See
"Initial evaluation of shock in children", section on 'Clinical classification of shock'.)
• Management issues include the following:
• ●Cardiogenic shock (as from myocarditis or a toxic ingestion) should be considered for any child without a readily apparent cause for
shock whose condition worsens with fluid therapy (table 10). (See "Clinical manifestations and diagnosis of myocarditis in children",
section on 'Clinical manifestations'.)
• ●Some children with poor cardiac function may also be volume depleted. Fluid should be administered slowly and in boluses of 5 to
10 mL/kg.
• ●Treatment with dobutamine or phosphodiesterase enzyme inhibitors can improve myocardial contractility and reduce systemic
vascular resistance (afterload). (See "Use of vasopressors and inotropes", section on 'Dobutamine'.)
• ●Cardiac arrhythmias (eg, supraventricular or ventricular tachycardia) should be addressed prior to fluid resuscitation (algorithm 3).
21/4/2022 55

56. Con’d
• Clinical presentation
- symptom depend on age infant; poor feeding, appétit
loss and can quickly progress to lethargy ,
-older child fatigue ,difficulty of breathing or chest
pain , as shock progress may experience syncope or
AMS
- tachycardia, tacypnea, week pulse, high JVP
,crackle, hepatomegally, coma
21/4/2022 56

57. • Cardiogenic shock – History of heart disease (eg,
corrected congenital heart disease or
cardiomyopathy), history of palpitations, signs of heart
failure (eg, pulmonary rales, hepatomegaly, gallop
rhythm, distended jugular veins), or arrhythmia
• However, a patient may have more than one type of
shock (such as an infant with cardiogenic shock from
supraventricular tachycardia who is also hypovolemic
because he has been unable to drink or a child with
underlying cardiomyopathy who is septic).
21/4/2022 57

58. Management
• Initial resuscitation
- stabilizing the airway ,breathing, circulation with
establishment of vascular access
- continues monitoring of vital signs, pulse oximetry
saturation
-chest compression indicated for bradicardia with poor
perfusion
21/4/2022 58

59. Con’d
• In low cardiac output state with hypotension
-optimization of preload by giving small NS bolus 5-
10ml /kg, with careful monitoring with hepatomegaly
and basal crepitation
-dopamine 10mcg/kg/min and/or doubutamine 10-
15mcg/kg/min infusion
- mechanical ventilation if patient in respiratory
distress or critically ill
21/4/2022 59

60. 21/4/2022 60
• cardiogenic shock is characterized by a decrease in myocardial
contractility, and presents a high mortality rate. Inotropic and
vasopressor agents have been recommended and used for several
years in the treatment of patients in shock, but they remain
controversial. Despite its beneficial effect on myocardial
contractility, the side effects of inotropic therapy (arrhythmias and
increased myocardial oxygen consumption) may be associated with
increased mortality. The pharmacodynamics of different inotropic
agents suggest benefits in specific situations, but these differences
have not been reflected in reduced mortality in most studies,
making it difficult to formulate recommendations

61. • In patients with cardiogenic shock, norepinephrine is
preferred over dopamine as the first-line vasopressor
because a subgroup analysis from a randomized trial
found that patients with cardiogenic shock who
received dopamine had a higher mortality than those
who received norepinephrine [28]. In addition,
dysrhythmias were more common in the dopamine
group.
21/4/2022 61

62. • Results: Literature was assessed to review the use of inotropes and
vasopressors in CS. Dopamine and adrenaline were associated with increased
mortality and arrhythmias. Dobutamine was associated with an improvement
in cardiac output, at the determinant of causing arrhythmias. Conversely,
noradrenaline was associated with a lower likelihood of arrhythmias and most
importantly decreased mortality in CS. Compared to other inotropes,
levosimendan appears to have a better safety profile and is associated with
decreased mortality in CS, particularly when combined with a vasopressor. Our
literature review suggests that treatment combination of the inotrope
levosimendan with the vasopressor noradrenaline may be the most effective
management option in CS.
21/4/2022 62

63. • For suspected cardiogenic shock, children who are
also hypovolemic should receive a smaller isotonic
crystalloid fluid bolus of 5 to 10 mL/kg, infused over
10 to 20 minutes. This approach decreases the
likelihood of exacerbating heart failure. cck
21/4/2022 63

64. Con’d
• In low cardiac output with normal blood pressure
-Frusamide infusion 0.05-0.1mg/kg/h to be added
-Add milirnon 0.1 -1mcg/kg/min
21/4/2022 64

65. Con’d
• Increased afterload state
-characterized by normalized HR, good central pulse,
weak peripheral pulse, cold periphery, BP normal to
high, hyperlactemia
-increase infusion rate of milirnon
21/4/2022 65

66. Con‘d
• After milirnon infusion ,tachycardia, good pulse, warm
periphery, decrease UOP, slightly low BP and
hyperlactemia consider hypovlumia and administer 5-
10ml/kg fluid bolus
• When optimal cardiac out put is achieved, good
normal pulse, warm extremity, good UOP, normal BP
and normal lactate maintain the same inotropic
support
21/4/2022 66

67. Con’d
- start weaning from ventilation in a stepwise manner
and plan extubation
- after extubation slow and gradual inotrope tapering
should be initiated after adding enalapril or captopril
- digoxin can be considered if there is reduced
contractility or for rate control
21/4/2022 67

68. Con’d
• Treatment of precipitating factor and specific
management of the underling cause
- correction of arrhythmia
- correction of anemia
- treatment of underling infection
- correction of electrolyte imbalance
21/4/2022 68

69. Case 4
• A 10 year old child with presented with sudden onset of
difficulty of breathing , lip and tongue swelling of1 hour,he also
has purities and strider at rest , 3 hours before while he was
playing at his yard he was stung on the forearm by bee, his
parent immediately placed ice over the area
PE ASL in RD,irritable BP 60/40 RR40 tem 36.7 o2 70% lip,tonge
uvula swelling
marked decrease air entry
How do you manage?
21/4/2022 69

70. Distributive shock
• Caused by inadequate vasomotor tone, which leads to
capillary leak and maldistribution of fluid into the
interstitium
• Abnormal vasodilatation and decreased SVR
• Significant decreases in both preload and after load
21/4/2022 70

71. • Distributive shock — Distributive shock is notable for a
marked decrease in systemic vascular resistance. Thus,
vasopressors are frequently employed along with fluid
therapy, depending upon the underlying etiology as
follows
21/4/2022 71

72. • Distributive shock – Distributive shock physiologically refers to a condition in which systemic vascular
resistance is initially decreased. It may occur as the result of sepsis, anaphylaxis, or neurologic injury. (See
"Pathophysiology and classification of shock in children", section on 'Distributive shock'.)
• With sepsis and anaphylaxis, volume depletion may also develop because of losses related to the underlying
infection (septic shock), or inflammatory cascade (anaphylaxis). Both processes are associated with increased
capillary permeability with loss of plasma from the intravascular space into the tissues. Myocardial
dysfunction can also contribute to poor tissue perfusion.
• In septic shock, abnormal distribution of blood flow as the result of changes in vasomotor tone causes
inappropriate tissue perfusion (such as decreased splanchnic circulation with increased flow to skin and
muscle). Systemic vascular resistance (SVR) may be low, producing increased blood flow to skin and a wide
pulse pressure (warm shock) or SVR may be increased, in which case, blood flow to skin is decreased and the
pulse pressure is narrow (cold shock). (See "Systemic inflammatory response syndrome (SIRS) and sepsis in
children: Definitions, epidemiology, clinical manifestations, and diagnosis", section on 'Clinical
manifestations'.)
21/4/2022 72

73. • Anaphylactic shock – A history of allergies and/or the presence of stridor,
wheezing, urticaria, or facial edema suggest anaphylaxis. Children with possible
anaphylaxis should receive intramuscular epinephrine, intravenous or
intramuscular diphenhydramine, and steroids, in addition to rapid infusions of
normal saline. Wheezing should be treated with nebulized albuterol. Patients
with cardiovascular collapse or those that respond poorly to intramuscular
epinephrine may require epinephrine intravenously (table 5 and table 8 and
table 9). (See 'Goal-directed approach' above and "Anaphylaxis: Emergency
treatment", section on 'Immediate management'.)
• ●
21/4/2022 73

74. • Neurogenic shock – Neurogenic shock refers to hypotension, usually with
bradycardia, attributed to interruption of autonomic pathways in the spinal
cord causing decreased vascular resistance. Patients with traumatic spinal cord
injury may also suffer from hemodynamic shock related to blood loss and other
complications. An adequate blood pressure is believed to be critical in
maintaining adequate perfusion to the injured spinal cord and thereby limiting
secondary ischemic injury. Appropriate mean arterial pressure for age should
be maintained using intravenous fluids, transfusion, and pharmacologic
vasopressors as needed. Bradycardia caused by cervical spinal cord or high
thoracic spinal cord disruption may require external pacing or administration of
atropine. (See "Acute traumatic spinal cord injury", section on 'Cardiovascular
complications'.)
21/4/2022 74

75. • Etiology
-anaphylaxis
-Neurologic: loss of sympathetic vascular tone
secondary to spinal cord or brainstem injury
-Drugs, Sepsis, hypoxia, poisoning
21/4/2022 75

76. Anaphylaxis
• Diagnosing criteria for anaphylaxis
• Highly likely when any one of the 3 criteria met
1 acute onset of illness( generalized
hives,itching,edema of lips and tongue or uvula) and
at least one of the following
-Respiratory symptom
- decreased BP or
21/4/2022 76

77. 2 two of the following that occur rapidly after exposure
to a likely allergen
- skin or mucosal symptom
- respiratory symptom,
-Decreased BP
- GI symptom
3 Decreased BP after exposure to known allergen
21/4/2022 77

78. • Diagnosis is made clinically:
• The most common signs and symptoms are cutaneous (eg,
sudden onset of generalized urticaria, angioedema, flushing,
pruritus). However, 10 to 20% of patients have no skin
findings.
• Danger signs: Rapid progression of symptoms, evidence of
respiratory distress (eg, stridor, wheezing, dyspnea,
increased work of breathing, retractions, persistent cough,
cyanosis), signs of poor perfusion, abdominal pain,
vomiting, dysrhythmia, hypotension, collapse
21/4/2022 78

79. • the first and most important therapy in anaphylaxis is epinephrine. There are NO absolute
contraindications to epinephrine in the setting of anaphylaxis.
• Airway: Immediate intubation if evidence of impending airway obstruction from
angioedema. Delay may lead to complete obstruction. Intubation can be difficult and should
be performed by the most experienced clinician available. Cricothyrotomy may be
necessary.
• IM epinephrine (1 mg/mL preparation): Epinephrine 0.01 mg/kg should be injected
intramuscularly in the mid-outer thigh. For large children (>50 kg), the maximum is 0.5 mg
per dose. If there is no response or the response is inadequate, the injection can be
repeated in 5 to 15 minutes (or more frequently). If epinephrine is injected promptly IM,
patients respond to one, two, or at most, three injections. If signs of poor perfusion are
present or symptoms are not responding to epinephrine injections, prepare IV epinephrine
for infusion (see below).
21/4/2022 79

80. • Place patient in recumbent position, if tolerated, and
elevate lower extremities.
• Oxygen: Give 8 to 10 L/minute via facemask or up to 100%
oxygen, as needed.
• Normal saline rapid bolus: Treat poor perfusion with rapid
infusion of 20 mL/kg. Re-evaluate and repeat fluid boluses
(20 mL/kg), as needed. Massive fluid shifts with severe loss
of intravascular volume can occur. Monitor urine output.
• Albuterol: For bronchospasm resistant to IM epinephrine,
give albuterol 0.15 mg/kg (minimum dose: 2.5 mg) in 3 mL
saline inhaled via nebulizer. Repeat, as needed.
21/4/2022 80

81. • Treatment of refractory symptoms:
• Epinephrine infusion¶: In patients with inadequate response to IM
epinephrine and IV saline, give epinephrine continuous infusion at
0.1 to 1 mcg/kg/minute, titrated to effect.
• Vasopressors¶: Patients may require large amounts of IV crystalloid
to maintain blood pressure. Some patients may require a second
vasopressor (in addition to epinephrine). All vasopressors should
be given by infusion pump, with the doses titrated continuously
according to blood pressure and cardiac rate/function monitored
continuously and oxygenation monitored by pulse oximetry.
21/4/2022 81

82. Management
• Airway management
-Supplemental oxygen, 6 to 8 liters by facemask, up to
100 percent, should be administered
- Intubation, cricothyroidotomy
• Fluid management
-Children should receive N/S 20 mL/kg each over 5 to
10 minutes, and repeated as needed
21/4/2022 82

83. • Epinephrine
- is the first choice in anaphylaxis
-recommended dose is 0.01 mg/kg (up to 0.5 mg per
dose), injected intramuscularly into the mid-
anterolateral thigh
-may be repeated at 5 to 15 minute intervals
21/4/2022 83

84. Adjuvant therapy
• Antihistamine
-relieve itch and hives
• Bronchodilator
- For the treatment of bronchospasm not responsive
to epinephrine
• Corticosteroid
- is to prevent the biphasic or protracted reactions
21/4/2022 84

85. Case 5
• A 4 year old child is brought to the ED after sustained
blunt chest trauma on P/E he is restless but
conscious, no bleeding from any area ,v/s BP is60/40
PR =60 full radial T=370c RR=40 o2 70%
Capillary refill is <2sec ,
resp trachea shifted to left ,hyperesonant right chest
cvs distended neck vein
how do you approach ?
21/4/2022 85

86. Obstructive shock
• Decreased cardiac Output secondary to direct
impediment to right or left sided heart outflow or
restriction of all cardiac chambers
• Etiology
Tension pneumothorax, pericardial tamponade,
Pulmonary embolism, anterior mediastinal masses,
Critical COA
21/4/2022 86

87. • Obstructive shock — Causes of obstructive shock (eg,
tension pneumothorax, cardiac tamponade,
hemothorax, pulmonary embolism, or ductal-
dependent congenital heart defects) require specific
interventions to relieve the obstruction to blood flow.
21/4/2022 87

88. • Life-threatening conditions — Life-threatening conditions that warrant prompt intervention and can be associated with
shock include:
• ●Angioedema with upper airway obstruction – Children with upper airway obstruction from anaphylaxis should receive
epinephrine (table 5). Intubation or a surgical airway may be necessary for patients with complete upper airway obstruction
or with no response to epinephrine. (See "Emergency evaluation of acute upper airway obstruction in children", section on
'Determining the cause of upper airway obstruction' and "The difficult pediatric airway", section on 'Approach to the failed
airway'.)
• ●Tension pneumo- or hemothorax – Tension pneumo- or hemothorax typically presents with severe respiratory distress,
asymmetric breath sounds, and poor perfusion and must be promptly decompressed. (See "Prehospital care of the adult
trauma patient", section on 'Needle chest decompression' and "Placement and management of thoracostomy tubes".)
• ●Cardiac tamponade – Patients with respiratory distress, poor perfusion, muffled heart tones, pulsus paradoxus,
hepatomegaly, and/or distended neck veins may have obstructive shock from cardiac tamponade. Fluid must be drained as
quickly as possible, preferably in the operating room. (See "Emergency pericardiocentesis", section on 'Technique overview'.)
21/4/2022 88

89. • ●Ductal dependent congenital heart defects – Infants under 28 days of age with a high clinical suspicion for ductal-dependent
congenital heart defects should receive prostaglandin E1 (also known as alprostadil). (See "Approach to the ill-appearing infant
(younger than 90 days of age)", section on 'Initial stabilization'.)
• ●Pulmonary embolism – Treatment for massive pulmonary embolism consists of supportive care, antithrombotic therapy (unless
otherwise contraindicated, as with patients who have had recent surgery), and, in selected patients, thromboembolectomy. (See
"Treatment, prognosis, and follow-up of acute pulmonary embolism in adults", section on 'Embolectomy' and "Venous thrombosis
and thromboembolism in children: Treatment, prevention, and outcome", section on 'Approach to treatment'.)
• ●Arrhythmia – Poor perfusion as a result of brady- or tachyarrhythmias requires immediate medical attention as follows:
• •Supraventricular tachycardia or ventricular tachycardia with poor perfusion should be treated with synchronized cardioversion (table
7). (See "Management and evaluation of wide QRS complex tachycardia in children", section on 'Unstable patient'.)
• •Children with bradycardia who are not hypoxic should receive epinephrine (or atropine if increased vagal tone or primary AV block is
suspected) and may require cardiac compressions (algorithm 4). (See "Pediatric advanced life support (PALS)", section on 'Bradycardia
algorithm'.)
21/4/2022 89

90. • Obstructive shock – Obstructive shock describes physical obstruction of
systemic blood flow from the heart which causes abrupt impairment of cardiac
output (table 1). Causes of obstructive shock include cardiac tamponade,
tension pneumo- or hemothorax and massive pulmonary embolism. Infants
with ductal-dependent congenital heart lesions, such as coarctation of the
aorta and hypoplastic left ventricle syndrome, may also present in shock when
the ductus arteriosus closes during the first few weeks of life. Conditions that
cause obstructive shock must be recognized quickly because they generally
require specific treatment. (See "Pathophysiology and classification of shock in
children", section on 'Obstructive shock' and "Approach to the ill-appearing
infant (younger than 90 days of age)", section on 'Initial stabilization'.)
21/4/2022 90

91. 21/4/2022 91

92. • Children with severe respiratory distress and signs of
circulatory compromise may have obstructive shock
21/4/2022 92

93. Management
• Fluid resuscitation may be briefly temporizing in
maintaining cardiac output
• The primary insult must be immediately addressed
-Pericardiocentesis for pericardial effusion
-Pleurocentesis or chest tube placement for
pneumothorax
-Thrombectomy/thrombolysis for Pulmonary embolism
21/4/2022 93

94. Management of shock in SAM
• Considered to have shock if he/she is lethargic or
unconscious and has cold hands plus either
- slow capillary refill (longer than three seconds), or
- weak, fast or absent radial or femoral pulses
21/4/2022 94

95. • Severe malnutrition – Intravenous fluid resuscitation in children with severe malnutrition and signs of shock is controversial [11].
Sunken eyes, lethargy, and tenting may occur from malnutrition alone and can cause clinicians to overestimate the degree of
dehydration [12]. Some experts believe that malnutrition causes sodium and water retention, overexpansion of the extracellular fluid,
and myocardial dysfunction [11,13-15]. Thus, rapid administration of intravenous fluids to infants and children who do not have fluid
depletion or physiologic changes associated with severe malnutrition or both may risk fluid overload, heart failure, and pulmonary
edema and is not recommended by the World Health Organization (WHO) [12,16].
• However, evidence suggests that the WHO recommendations for fluid resuscitation in severely malnourished may be too restrictive.
For example, in an observational study of fluid resuscitation in 149 severely malnourished children with cholera and severe
dehydration, infusion of approximately 20 mL/kg per hour of an isotonic saline solution over four to six hours was not associated with
heart failure in any patient, and all patients survived [17]. Furthermore, in a clinical trial of 61 children with severe malnutrition
accompanied by decompensated shock in the majority of patients, administration of 30 to 40 mL/kg of crystalloid fluids over two
hours failed to reverse shock in over half of patients and was accompanied by high mortality [11].
• Thus, pending further study, some experts suggest that severely malnourished children receive fluid resuscitation with careful
reassessment according to the WHO guidelines for children with shock and no signs of malnutrition.
21/4/2022 95

96. If the child in shock
• Give O2 for infant 0.5l/min and for older children 1-2 l/min
• Give sterile 10% glucose 5ml/kg by iv
• Keep child warm
• Give iv fluid
-Infuse IV fluid at 15ml/kg over 1 hour
- Repeat the same amount of IV fluids for another hour if
child improving
21/4/2022 96

97. • After two hours of IV fluids, switch to oral or NG
rehydration with ReSoMal
-Give 5-10 ml/kg ReSoMal in alternate hours with F-75
for up to 10 hours or until fully rehydrated
-If the respiratory rate and pulse rate increase and
child is gaining weight, stop the IV rehydration and
assume septic or cardiogenic shock
21/4/2022 97

98. • If no improvement after 1st hour of iv fluids ,then
assume septic shock
• Then transfuse 10ml/kg slowly over 3 hours
• If there are signs of heart failure, give packed cells
21/4/2022 98

99. 21/4/2022 99

100. • DKA: diabetic ketoacidosis.
• * For possible cardiogenic shock with hypovolemia, give 5 to 10 mL/kg of isotonic fluids (eg,
normal saline or Ringers lactate), infused over 10 to 20 minutes. Evaluate target endpoints
and slowly give another 5 to 10 mL/kg if there has been improvement or no change. For
patients with diabetic ketoacidosis, give 10 mL/kg of isotonic fluids over one hour.
• ¶ Such as inotropes or vasodilators. For newborns, prostaglandin E1. Refer to UpToDate
topics on management of cardiogenic shock in children and management of neonates with
cyanotic heart disease.
• Δ For patients with DKA who do not improve with 20 mL/kg, look for another cause of shock
before administering additional crystalloid. For possible cardiogenic shock, slowly give
another 5 to 10 mL/kg if there has been improvement or no change.
21/4/2022 100

101. • MONITORING — Effective management of children with shock requires frequent adjustment of therapeutic interventions based upon
continuous hemodynamic monitoring and assessment of end organ perfusion (brain, kidneys, and skin).
• Monitoring should include continuous noninvasive measurement of heart rate and pulse oximetry with frequent measurement of
blood pressure. In addition to these parameters, the following clinical features should also be observed before and after each fluid
bolus (see 'Physiologic indicators and target goals' above):
• ●Quality of central and peripheral pulses
• ●Skin perfusion (as indicated by temperature and capillary refill)
• ●Mental status
• ●Auscultation of lung and heart sounds
• ●Palpation of liver edge (to identify hepatomegaly as a sign of heart failure)
21/4/2022 101

102. • More aggressive monitoring may be necessary for children who do not improve with fluid resuscitation. (See 'Goal-directed approach'
above.)
• Interventions to consider include:
• ●A urinary catheter should be placed to monitor urine output.
• ●Children receiving vasoactive infusions should generally have arterial pressure monitoring after initial resuscitation. Placement of
intraarterial catheters may occur in the emergency department or intensive care unit, depending upon resources. (See "Arterial
puncture and cannulation in children", section on 'Arterial cannulation'.)
• ●Children with fluid and catecholamine-resistant shock should be expeditiously transferred to intensive care units where central
venous pressure (CVP) and central venous oxygen saturation (ScvO2) can be monitored. CVP is an indication of preload. A
measurement of <8 mmHg suggests that fluid resuscitation has been inadequate.
• ●ScvO2 measurements provide information regarding oxygen supply and consumption at the tissue level as an indication of
perfusion. Experts recommend a target ScvO2 of >70 percent as an indication of adequate perfusion [2]. In adults, lactate clearance is
considered a reasonable alternative to measurement of ScvO2, but data in children are limited. (See "Evaluation and management of
suspected sepsis and septic shock in adults".)
21/4/2022 102

103. • PITFALLS — The management of children with shock is challenging. Some pitfalls include:
• ●Failure to recognize nonspecific signs of compensated shock (ie, unexplained tachycardia, abnormal mental
status, or poor skin perfusion)
• ●Inadequate monitoring of response to treatment
• ●Inappropriate volume for fluid resuscitation (usually too little for children with sepsis or hypovolemic shock,
but possibly too much for those with cardiogenic shock)
• ●Failure to reconsider possible causes of shock for children who are getting worse or not improving
• ●Failure to recognize and treat obstructive shock
21/4/2022 103

104. prognosis
• In septic shock, mortality rates are;
-As low as 3% in previously healthy children
-And 6–9% in children with chronic illness
• With early recognition and therapy, the mortality rate
for pediatric shock continues to improve
• Shock and MODS remain one of the leading causes of
death in infants and children
21/4/2022 104

105. Reference
• Nelson 2021 edition
• Up-to-date
• Pediatrics emergency management protocol 2021 2nd
edition
• SAM gridline 2020 3rd edition
• JAMMA and PUBMED pediatrics journal
21/4/2022
105

106. 21/4/2022 106

107. • Distributive – Decreased vascular resistance due to vasodilation caused by
conditions such as sepsis, anaphylaxis, or acute injury to the spinal cord or
brain
• ●Cardiogenic – Decreased cardiac contractility caused by conditions such as
primary myocardial injury, arrhythmias, cardiomyopathy, myocarditis,
congenital heart disease with heart failure, sepsis, or poisoning
• ●Obstructive – Increased vascular resistance caused by conditions such as
congenital heart disease with ductal dependent lesions (eg, hypoplastic left
heart), or acquired obstructive conditions (eg, pneumothorax, cardiac
tamponade, or massive pulmonary embolism)
21/4/2022 107

108. • Hypotensive hypovolemic or distributive shock – We recommend that children with hypotensive hypovolemic or distributive shock (as
from gastrointestinal losses, traumatic hemorrhage, sepsis, or anaphylaxis), receive 20 mL/kg per bolus of isotonic crystalloid, such as
normal saline or Ringer's lactate solution, infused over 5 to 10 minutes and repeated, as needed, up to four times in patients without
improvement and no signs of fluid overload [2,6,7]. Additional therapies, such as blood transfusion in patients with hypovolemic
shock from hemorrhage or vasoactive drug therapy and corticosteroid administration in patients with septic shock may be required
depending upon the response to fluid administration. (See 'Hypovolemic shock' below and 'Distributive shock' below.)
• Observational studies of rapid fluid resuscitation as a component of goal-directed therapy and in conjunction with other critical care
interventions such as prophylactic endotracheal intubation with mechanical ventilation and close monitoring by pediatric critical care
specialists has been associated with a marked decrease in mortality, especially in children with hypotensive septic shock. (See
'Evidence for goal-directed therapy in children' below.)
• Techniques to rapidly deliver intravenous fluid include gravity, applying pressure directly to the bag of fluid with an inflatable device,
delivering aliquots of fluid using a large syringe that is refilled through a three-way stopcock attached to the bag (the "push-pull"
method) or use of rapid infusion pumps designed to deliver high volumes of warmed fluids or blood. Gravity alone is likely insufficient
to deliver 20 mL/kg over 5 to 10 minutes. This was demonstrated in a randomized trial that compared the rate at which fluid could be
delivered to 57 children requiring fluid resuscitation using gravity, an inflatable pressure bag, or a "push-pull" method [8]. The median
volume of fluid delivered over five minutes by gravity was 6.2 mL/kg, in comparison to 20.9 mL/kg for the pressure bag and 20.2
mL/kg for the "push-pull" method. These differences remained significant after controlling for intravenous catheter gauge, age, and
weight.
• ●
21/4/2022 108

109. • Compensated hypovolemic or distributive shock – We suggest that children
with compensated hypovolemic or distributive shock receive 20 mL/kg per
bolus of isotonic crystalloid, such as normal saline or Ringer's lactate solution
over 5 to 20 minutes. Patients should be closely monitored during fluid
administration. Additional fluid boluses may be indicated depending upon the
patients’ response. Evidence suggests that overly aggressive fluid bolus may be
harmful in selected patients, including those with cardiogenic shock, DKA,
syndrome of inappropriate antidiuretic hormone secretion, severe
malnutrition, or, in resource-limited settings, severe febrile illness in the
absence of dehydration or hemorrhage. (See 'Risks' below.)
21/4/2022 109

110. • Cardiogenic shock – For suspected cardiogenic shock
in patients with signs such as a gallop rhythm,
pulmonary rales, jugular venous distension, or
hepatomegaly, a smaller isotonic crystalloid fluid bolus
of 5 to 10 mL/kg, infused over 10 to 20 minutes
decreases the likelihood of exacerbating heart failure
21/4/2022 110

111. • Cardiogenic shock – Although many children with
cardiogenic shock have some degree of hypovolemia,
fluids should be administered slowly and in boluses of
5 to 10 mL/kg in such patients to avoid worsening
myocardial insufficiency and pulmonary edema.
Clinical findings of cardiogenic shock include gallop
rhythm, jugular venous distension, pulmonary rales,
and hepatomegaly.
21/4/2022 111

112. • EARLY GOAL-DIRECTED THERAPY — Early goal-directed therapy for shock refers to an aggressive systematic approach to resuscitation targeted to improvements in physiologic
indicators of perfusion and vital organ function within the first six hours. Targeted interventions are determined by degree of illness and response to treatment within the first
hour of care. This approach has been most strongly promoted for children with septic shock. (See "Septic shock in children: Rapid recognition and initial resuscitation (first
hour)", section on 'Resuscitation'.)
• Early goal-directed therapy for septic shock in adults is discussed in detail separately. (See "Evaluation and management of suspected sepsis and septic shock in adults".)
• Physiologic indicators and target goals — Physiologic indicators that should be targeted during therapy (with goals in parentheses) include [2]:
• ●Blood pressure (systolic pressure at least fifth percentile for age: 60 mmHg <1 month of age, 70 mmHg + [2 x age in years] in children 1 month to 10 years of age, 90 mmHg in
children 10 years of age or older)
• ●Quality of central and peripheral pulses (strong, distal pulses equal to central pulses)
• ●Skin perfusion (warm, with capillary refill <2 seconds)
• ●Mental status (normal mental status)
• ●Urine output (≥1 mL/kg per hour, once effective circulating volume is restored)
21/4/2022 112

113. • Heart rate is an important physiologic indicator of
circulatory status. For children with shock, tachycardia is
often a compensatory response to poor tissue perfusion. In
this situation, a decrease in heart rate with fluid therapy can
be a valuable indicator of improved perfusion in response to
treatment (table 2). However, many other factors (ie, fever,
drugs, hypoxia, and anxiety) influence heart rate. In
addition, an abnormal heart rate may be the direct result of
the cause of shock (as with myocarditis or beta blocker
ingestion). Although trends in response to treatment should
be carefully monitored, specific target goals for heart rate
are difficult to define and may not be useful.
21/4/2022 113

114. • Cardiogenic shock – For suspected cardiogenic shock
in patients with signs such as a gallop rhythm,
pulmonary rales, jugular venous distension, or
hepatomegaly, a smaller isotonic crystalloid fluid bolus
of 5 to 10 mL/kg, infused over 10 to 20 minutes
decreases the likelihood of exacerbating heart failure.
(See 'Cardiogenic shock' below.)
21/4/2022 114

115. • Cardiogenic shock – Although many children with
cardiogenic shock have some degree of hypovolemia,
fluids should be administered slowly and in boluses of
5 to 10 mL/kg in such patients to avoid worsening
myocardial insufficiency and pulmonary edema.
Clinical findings of cardiogenic shock include gallop
rhythm, jugular venous distension, pulmonary rales,
and hepatomegaly
21/4/2022 115

116. • Choice of fluid — Fluid therapy for children with shock should begin with isotonic crystalloid, such as normal
saline or Lactated Ringers solution, as supported by the following evidence:
• ●Randomized trials and meta-analyses have failed to consistently demonstrate a difference between colloid
and crystalloid for the treatment of shock in adults. (See "Treatment of hypovolemia (dehydration) in
children", section on 'Crystalloid versus colloid' and "Treatment of hypovolemia or hypovolemic shock in
adults", section on 'Colloid versus crystalloid'.)
• ●For children, randomized trials comparing colloid with crystalloid for hypotensive newborns and for children
with dengue shock syndrome have not demonstrated a difference between the solutions [19-22].
• ●Colloid solutions are more expensive and patients may develop adverse reactions to them.
• ●Many patients in shock are hyperglycemic. Although identification and treatment of hypoglycemia is very
important, the rapid infusion and large amounts of bolus fluids to treat shock necessitate exclusion of glucose
from the resuscitation fluids.
21/4/2022 116

117. • Fluid administration — Limited evidence exists concerning the optimal amount and rate of
fluid administration for children with shock. Several studies support the use of isotonic
crystalloid fluid bolus (ie, normal saline or Ringers Lactate) as a component of goal-directed
therapy for shock other than obstructive shock (eg, tension pneumothorax, pericardial
tamponade, or massive pulmonary embolus). However, aggressive fluid resuscitation may
be harmful for children who are not hypovolemic or have compensated shock with certain
comorbidities (eg, cardiac disease, diabetic ketoacidosis [DKA], syndrome of inappropriate
antidiuretic hormone secretion [SIADH], severe malnutrition, or malaria). Patients with
obstructive shock should receive emergent correction of the underlying cause (eg, needle or
chest tube thoracostomy for tension pneumothorax or pericardiocentesis for cardiac
tamponade). Neonates with ductal dependent lesions and circulatory collapse may also be
hypovolemic. However, primary treatment should focus on reopening the ductus arteriosus
with prostaglandin E1 (alprostadil). (See 'Evidence for goal-directed therapy in children'
below and 'Risks' below and 'Obstructive shock' below.)
21/4/2022 117

118. 21/4/2022 118

119. THANK YOU
21/4/2022 119