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Emergency Room Management of Shock Dr Nishant Verma Assistant Professor Department of Pediatrics, KGMU © Nishant Verma Carcillo JA et al. Mortality and Functional Morbidity After Use of PALS/APLS by Community Physicians. Pediatrics 2009;124;500 No shock Tachycardia Shock N = 4856 Mortality rates increase according to the degree of hemodynamic abnormality at presentation to the community hospital. 2 Carcillo JA et al. Mortality and Functional Morbidity After Use of PALS/APLS by Community Physicians. Pediatrics 2009;124;500 Early reversal of any hemodynamic abnormality in the community hospital was associated with improved outcome. 3 A case scenario Define Shock A previously healthy 12yr boy complains of severe malaise and shortness of breath. He describes onset of fever, pustular Types of Shock skin lesions and left knee swelling 2 days prior to his arrival in ER. O/E, he is alert but clearly ill and severely tachycardic (HR Assessment of Shock 160bpm). He has brisk capillary refill, bounding pulses and a BP of 100/36 mmHg. He receives 250ml NS over 1hr and is Stages of Shock then transferred to PICU. On arrival he is noted to be obtunded, with extremely poor perfusion and undetectable BP. He is resuscitated with great difficulty and survives, albeit with renal insufficiency. Early Goal-directed management 4 What is shock ? Oxygen Delivery Oxygen Demand Oxygen Delivery = Arterial O2 content (CaO2) x Cardiac output (CO) CaO2 = (Hb x 1.34 x SaO2) + (0.003 x PaO2) CO = HR x Stroke volume Stroke volume : Function of Preload, Afterload & Myocardial Contractility 5 Stages of shock Initial Insult Triggers shock Decreased perfusion Body’s compensatory mechanism Compensated shock Decompensated shock Tissue damage Multisystem organ failure © Nishant Verma Death 6 Types of shock Hypovolemic Shock Distributive Shock Cardiogenic Shock Obstructive Shock Septic Shock © Nishant Verma 7 Stages of Septic shock + Prognosis - -- Tachycardia Flushed Brisk capillary refill Bounding pulses Wide pulse pressure + + Cardiac CardiacOutput Output Warm shock Warm Cold © Nishant Verma Cold shock Tachycardia Mottled Delayed refill Thready pulses Narrow pulse pressure Hypotension 8 Assessment of a child in shock ABCD for any sick child in ER Airway Breathing Circulation Not able to maintain airway Not breathing GCS < 8 INTUBATE Disability / Dextrose © Nishant Verma 10 Hemodynamic assessment GOALS •Identify Shock •Identify the type of shock •Identify the stage of shock •Monitor treatment response © Nishant Verma 11 Assessment Signs of dehydration Mucosa, eyes, skin turgor. Vitals HR, RR, Pulse vol, BP Color, CFT, Core-periphery temp diff Pulse oximetry Continuous ECG Signs of overload Gallop rhythm Hepatomegaly Rales on auscultation Adequacy of organ perfusion Urine output Mental status Arterial Lactate Focused history © Nishant Verma 12 Hypotension: a word of caution ! • Never wait for hypotension to set in • Late sign in pediatric shock • Indicates decompensated state • Act as soon as you notice – Tachycardia / Impaired perfusion © Nishant Verma 13 Management of Shock 15 Crit Care Med 2009; 37:666–688 Emergency Room Management GOALS • Normal mental status • Normal Peripheral perfusion (CFT < 3 s) • Palpable distal pulses • Normal blood pressure for age • Urine output > 1ml/kg/hr • Threshold HR 17 © Nishant Verma STEP 1 0 - 5min • Identify shock • Begin oxygen • Establish vascular access – IV – IOIntra Osseous – Secure 2 lines FLUID BOLUS INOTRPOES © Nishant Verma 18 STEP 2 5-15min • Fluid resuscitation – Fluid type – Crystalloids vs NS/RL Colloids Crystalloid – Amount – 20ml/kg boluses, push over 5-10 min 20ml/kg 5-10min • Cautious in cardiogenic shock, newborns – How much to give ? Assess response • Assess response after each bolus • Watch for signs of overload Watch for overload • Usually 40-60ml/kg © Nishant Verma 19 STEP 2 • • • • 5-15min Correct hypoglycemia Correct hypocalcemia Begin Antibiotics for suspected septic shock If 2nd IV line available – Consider inotrope Shock not reversed Fluid Refractory Shock 20 © Nishant Verma STEP 3 15-60min Fluid Refractory Shock • Obtain central access (ketamine) • Start central inotrope Cold shock Warm shock Dopamine (5-20 mcg/kg/min) Adrenaline (0.05-1 mcg/kg/min) Norepinephrine (0.05-1 mcg/kg/min) Shock not reversed Catecholamine resistant Shock 21 STEP 3 15-60min Catecholamine resistant shock • Consider Hydrocortisone – Indications Fluid-refractory, catecholamine-resistant shock and suspected or proven adrenal insufficiency – Dose – 50mg/m2/day to 50 mg/kg/day Stress dose Shock dose • Transfer to PICU © Nishant Verma 22 Golden Hour of Shock Management Recognition, oxygen, access Rapid fluid boluses, glucose, antibiotics Additional IV/intraosseous access 5 15 First Hour Secure airway, central access Begin to titrate vasoactive agent Hydrocortisone if at risk for adrenal insufficiency Titrate fluid resuscitation, inotropes with serial exams, supportive care until transport to PICU © Nishant Verma 23 PICU Management Therapeutic end points • • • • • • • • CFT ≤2 s Normal BP Normal peripheral and central pulses Warm extremities Urine output > 1 mL/kg/hr, Normal mental status ScvO2 saturation > 70% Cardiac index - 3.3 - 6.0 L/min/m2 © Nishant Verma 25 PICU management • Establish arterial line • Monitor CVP – Attain normal MAP – CVP Term NB – 55 mmHg Upto 1yr – 60 mmHg 2-15yr - 65 mmHg • Monitor ScvO2 – Target > 70% • Consider Mechanical ventilation © Nishant Verma 26 Inotropic and Vasoactive drugs INOTROPES Drug Inotropy Vasoconstriction Vasodilation Dopamine +++(β1) ++(ɑ) -(D) (5-10mcg/kg/min) (>10mcg/kg/min) (<2mcg/kg/min) +++ - ++ Dobutamine (β1) (β2) Adrenaline +++ ++ + Noradrenaline - +++ - Vasopressin - +++ - NTG/NTP - - +++ Milrinone +++ - ++ Enoximone +++ - + Levosimendan +++ - + VASOPRESSORS VASODILATOR INODILATORS © Nishant Verma 27 PICU management Catecholamine resistant Shock Cold shock with Normal BP •Titrate fluid and epinephrine •Consider vasodilators (NTG, Milrinone, Levosimendan) Cold shock with Low BP Maintain Hb > 10 Warm shock with Low BP •Titrate fluid and epinephrine •Titrate fluid and norepinephrine •If still hypotensive, consider norepi •If still hypotensive, consider vasopressin •Consider inodilators •Consider low dose adre 28 © Nishant Verma PICU management Shock not reversed Shock not reversed Refractory shock: ECMO © Nishant Verma 29 Supportive care • Blood products • Glycemic control • Diuretics and renal replacement © Nishant Verma 30 Questions © Nishant Verma 31 Case scenarios Case 1 A 2-year-old previously healthy boy develops profuse diarrhea, vomiting, and lethargy Heart rate 176/min, blood pressure 78/60 mm Hg, respiratory rate 40/min, temperature 96.7°F, SpO2 98% Child arouses to needle sticks, is extremely mottled, and has thready pulses Clear lungs and precordium, abdomen is scaphoid and non- tender What is your impression? What is your initial management? © Nishant Verma 33 Case 1 Hypovolemic Shock Start high flow oxygen Achieve prompt IV or intraosseous access Provide rapid bolus with isotonic crystalloid Correct hypoglycemia if present Provide additional fluid boluses as indicated, consider possible ongoing losses © Nishant Verma 34 Case 2 – A 3-week-old infant is evaluated for lethargy, poor feeding, rapidly worsening appearance, and evolving respiratory distress – Heart rate 190/min, blood pressure 60/46 mm Hg, respiratory rate 70/min, SpO2 95%, temperature 38.0°C (100.3°F) – Mottled, thready upper extremity pulses, and cold lower extremities – Lung fields have crackles and liver is enlarged – Bedside glucose is 90 mg/dL, arterial blood gas shows a pH of 7.16 with a pCO2 of 20 mm Hg. Ionized calcium is normal What type of shock is this? What is your management plan? © Nishant Verma 35 Case 2 Cardiogenic Shock Due to Ductal-Dependent Lesion ABCs with urgent vascular access Evaluate response to small (5-10 mL/kg) fluid boluses Begin prostaglandin infusion (0.05 mcg/kg/min) until echocardiogram excludes duct-dependent congenital heart disease Support circulation with volume, inotropes as required Urgent consultation with a cardiologist © Nishant Verma 36 Case 3 – A 12-year-old 25kg inpatient with flu and knee pain collapses in his room. You are called to evaluate him in the pediatric ward – Heart rate 168/min, respiratory rate 56/min, temperature 94.9°F, – BP 70/30 mm Hg, SpO2 96% on non-rebreather face mask – Barely responsive to painful stimuli – Skin mottled, distal pulses are imperceptible – Lungs are clear, without retractions – Unremarkable precordium and abdomen – Left knee is obviously inflamed – No urine output Start Dopa to PICU. Transferred After Secure access, 1000ml measure NS over CVP 15min, develops Child receiving receives 500ml NS over 30min. What iscentral your diagnosis? Still in what and next rales, ? still hypotensive, CFT>3, mottled. Is it hepatomegaly appropriate ? of What isshock, your plan management ? WhatAdrenaline Start next ? 37 © Nishant Verma Case 4 – A 16-month-old with cough presents in progressive respiratory and cardiovascular failure – The child is sedated, intubated, and ventilated. Heart rate 200/min, blood pressure 82/66 mm Hg, respiratory rate 32/min, temperature 37°C (98.5°F), SpO2 100% on 80% oxygen – Skin is mottled, poor distal pulses – Breath sounds are diminished on the right – The abdomen is unremarkable What additional study would you consider? What is your management plan? 38 Case 4 Obstructive Shock Needle aspiration with eventual chest tube placement Fluid bolus administered (10-20 mL/kg of IV normal saline or lactated Ringer’s) Use caution with medications with the potential for vasodilation – Morphine – Propofol – Benzodiazepines © Nishant Verma 39 Key Points Rapid recognition of shock is essential to good outcomes Don’t wait for Hypotension to set in Initiate management of ABCs with particular attention to rapid fluid resuscitation, early antibiotics, and consider prostaglandin E in neonates More conservative with fluids in cardiogenic shock (5-10 mL/kg aliquots) Management should be directed at normalizing tissue perfusion and blood pressure (Goal directed) Frequent/Continuous monitoring as appropriate If patient is not responding the way you think broaden your differential, think about other types of shock © Nishant Verma 40 “You may delay, but time will not.” Benjamin Franklin Thank You