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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
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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
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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
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Types of shock
Hypovolemic Shock
Distributive Shock
Cardiogenic Shock
Obstructive Shock
Septic Shock
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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
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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
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Hemodynamic assessment
GOALS
•Identify Shock
•Identify the type of shock
•Identify the stage of shock
•Monitor treatment response
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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
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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
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Management of Shock
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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
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© Nishant Verma
STEP 1
0 - 5min
• Identify shock
• Begin oxygen
• Establish vascular access
– IV
– IOIntra Osseous
– Secure 2 lines
FLUID BOLUS
INOTRPOES
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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
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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
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© 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
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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
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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
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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
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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
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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
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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
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© Nishant Verma
PICU management
Shock not reversed
Shock not reversed
Refractory shock:
ECMO
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Supportive care
• Blood products
• Glycemic control
• Diuretics and renal replacement
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Questions
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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
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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
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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
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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
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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?
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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
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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
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“You may delay, but
time will not.”
Benjamin Franklin
Thank You