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Chapter 47 Shock, Multiple Organ Dysfunction Syndrome, and Burns in Children Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Shock and Multiple Organ Dysfunction Syndrome (MODS) Shock Commonly results from hemorrhage, severe dehydration, progressive heart failure, or sepsis Compensated shock Decompensated shock Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 2 Shock Hypovolemic shock Distributive or vasogenic shock Neurogenic shock Cardiogenic shock Septic shock Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Shock Dehydration, hypovolemia, low cardiac output stimulate adrenergic and renal compensation Tachycardia Redistribution of blood from the skin, gut, and kidney to the brain and heart Reduced renal perfusion stimulates the reninangiotensin-aldosterone system, resulting in renal sodium and water retention Neonatal and young infant kidneys are incapable of excreting concentrated urine Compensatory mechanisms are relatively ineffective during the first weeks of life Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Reperfusion Injury Cellular damage caused by the restoration and reperfusion of oxygen to cells that have been exposed to reversible hypoxic conditions Occurs from the generation of highly reactive oxygen intermediates The amount of free oxygen radical production depends on the severity and duration of the ischemic period Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Evaluation of Shock Arterial blood gas (ABG) Serum lactate concentration Blood pressure Ventilation and oxygenation Chemistry analytes Electrolytes, glucose, BUN, liver function, calcium, phosphorus, cardiac enzymes Hemoglobin and hematocrit Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Treatment of Shock Adequate oxygen delivery Monitor body temperature Transfusion of blood components IV fluids (volume resuscitation) Monitor urine output and specific gravity Monitor blood pressure Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Emerging Therapies for Shock and Sepsis Injury prevention Haemophilus influenzae and Neisseria meningitidis vaccines Colony-stimulating factors to increase white blood counts in immunocompromised individuals Infectious disease control Resuscitation techniques Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Emerging Therapies for Shock and Sepsis Mediator-specific therapies Continuous plasma filtration Glucocorticoid administration Activation of Toll-like receptors Genetic profiling Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Multiple Organ Dysfunction Syndrome (MODS) Failure of at least two organs that results from a single cause Risk factors: sepsis, trauma, cardiopulmonary arrest, congenital heart disease, liver/bone marrow transplantation Children with chronic diseases have an increased risk and increased mortality Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Burns A common result of inadequate supervision, curiosity, inability to escape the burning agent, or intentional abuse Child abuse 6% to 20% of child burn injuries are child abuse Pattern burns, forced emersion burns, splash/spill burns, cigarette burns Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Burns Scald injuries Contact burns Flame burns Electrical burns Chemical burns Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Severity of Injury Total body surface area (TBSA) Rule of nines inaccurate in children Arms and trunk demonstrate same proportions as an adult Head and neck—18% Each lower extremity—14% Depth of injury Infant skin is extremely fragile and more likely to sustain a deeper burn Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Severity of Injury Age Younger than 2 years, a significantly higher risk for associated morbidity and mortality Have not achieved maturity of immune system and are at increased risk for infection and sepsis Very young children are intolerant of rapid fluid shifts; immature renal function negatively affects ability to retain sodium and water Areas of the body burned Secondary injuries and manifestations Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Burn Injury in Children Integumentary system Cardiovascular system Renal system Gastrointestinal system Metabolism Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Burn Injury in Children Immune function Scar maturation Burn shock Pulmonary system Infection Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Burn Injury in Children Functional limitations Fluid resuscitation Wound management Pulmonary support Nutritional support Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Burn Injury in Children Comfort management Community reintegration Mosby items and derived items © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 18
