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Definition
Circulatory system failure to supply
oxygen and nutrients to meet cellular
metabolic demands .
Shock
Classification and causes:
Hypovolemic
Distributive
Cardiogenic
Obstructive
dissociative
Hemodynamics
Myocardial
Contractility
Stroke Volume
Cardiac Output
Blood
Pressure
Preload
Afterload
Heart Rate
Systemic Vascular
Resistance
Textbook of Pediatric Advanced Life Support, 1988
Cardiovascular function
Cardiac Output
CO = HR x SV
HR responds the quickest
SV is a function of three variables :
preload,
After load,
myocardial contractility
A noncompliant heart cannot increase SV
Cardiovascular function
1-Cardiac Output
2-Clinical Assessment
peripheral perfusion
Temperature
capillary refill
urine output
Mentation
acid-base status
Hypovolemic shock
Definition:
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Decreased circulating blood volume.
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Common causes:
Hemorrhage
Diarrhea
Diabetes insipidus
Diabetes mellitus
Burns
Adrenogenital syndrome
Distributive shock
 Definition
Vasodilation and decreased preload
Common causes:
Sepsis
Anaphylaxis
Spinal injury
Drug intoxication
Cardiogenic shock
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Decreased myocardial contractility
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Common causes:
Congenital heart disease
Severe heart failure
Arrhythmia
hypoxic ischemic injuries
Cardiomyopathy
Myocarditis
Drug intoxication
kawasaki
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Obstructive shock
Definition
Mechanical obstruction to ventricular
outflow.
Common causes:
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Cardaic tamponade
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Massive pulmonary embolus
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Tension pneumothorax
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Cardiac tumor
Dissociative shock
Definition
 Oxygen not released from hemoglobin.
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1.
2.
Common causes
Carbon monoxide poisoning
methemoglobinemia
Organ directed therapeutics
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Cardiovascular support
Fluid resuscitation
Cardiotonic and vasodilator therapy
Respiratory support
Renal salvage
Cardiovascular Changes in Shock
Type
Preload
Afterload
Contractility
Cardiogenic
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Hypovolemic
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Distributive
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No change
Septic
early
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late
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Evaluation
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Regardless of the cause: ABC
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First assess airway patency
ventilation
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then circulatory system
Evaluation
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Respiratory Performance
Respiratory rate and pattern
 work of breathing
 oxygenation (color)
 level of alertness
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Circulation
Heart rate, BP, perfusion, and pulses, liver
size
 CVP monitoring may be helpful
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Evaluation
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Early Signs of Shock
 sinus tachycardia.
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delayed capillary refill.
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fussy, irritable.
Late Signs of Shock
Evaluation
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Late Signs of Shock
bradycardia
 altered mental status (lethargy, coma)
 hypotonia, decreased DTR’s
 Cheyne-Stokes breathing
 hypotension is a very late sign
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Cardiovascular Assessment (con)
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CNS Perfusion
Recognition of parents
 Reaction to pain
 Muscle tone
 Pupil size
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Renal Perfusion
 UOP >1cc/kg/hr
Cardiovascular Assessment (con)
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Skin Perfusion
Capillary refill time
 Temperature
 Color
 Mottling
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Therapy for shock
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The key therapy is the recognition of
shock in its early state.
Treating the signs and symptoms.
Minimize cadiopulmonary work.
Ensuring cardiac output blood pressure
and gas exchange
Hypovolemic Shock
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Mainstay of therapy is fluid .
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Goals:
1.
2.
3.
Restore intravascular volume
Correct metabolic acidosis
Treat the cause
Hypovolemic Shock (treatment)
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Degree of dehydration often underestimated
 Reassess perfusion, urine output, vital signs...
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Isotonic crystalloid is always a good choice
 20 to 50 cc/kg rapidly if cardiac function is
normal
 NS can cause a hyperchloremic acidosis
Other Studies
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Look for etiology of shock.
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Evaluate hemoglobin, hematocrit, and platelet count.
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Shock from any etiology can lead to DIC and end organ
damage
Other Studies
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CBC, PT, INR, PTT, Fibrinogen, Factor V,
Factor VIII
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Check LFT’s, follow CNS and pulmonary
status
Conclusion
Goal of therapy is;
identification
evaluation
and treatment of shock in its earliest stage
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Successful resuscitation depends on early
and judicious intervention
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Initial priorities are for the ABC’s
Conclusion
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Fluid resuscitation begins with 20cc/kg of
crystalloid or 10cc/kg of colloid
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Subsequent treatment depends on the
etiology of shock and the patient’s
homodynamic condition
Related infection and shock
Infection
 Bacteremia
 Systemic inflammatory response syndrome :
(2 or>2 of following)
(T>38
HR>90
RR>20
WBC>12000 or<4000)
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Related infection and shock
Sepsis:
Systemic response to infection
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Sever sepsis:
sepsis + organ dysfunction
(hypo perfusion, lactic acidosis, oliguria,or an
acute alter mental status)
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Related infection and shock
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Septic shock:
sepsis +hypotention despid adequate fluid
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Hypotention:
systolic<9 or >4reduction
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Multiple organ dysfuntion
Burns
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Disruption 3 key function of skin
1.
Regulation of heat loss
presevation of body fluid
Barrier of the infection
2.
3.
Patophisiology
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Release inflammatory and vasoactive
mediators
capillary permeability increase
Decrease plasma volume and cardiac
output
Shock is common if borne > 10% -12%
classification
1.
2.
3.
4.
Depth of injury
Percent of body surface area involved
Location of the burn
Association with other injuries
Clinical manifestation
1-First – degree:
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Red, painful dray
Superficial and limited to epidermis.
Heal in 3-6 days
Clinical manifestation
2-Second degree:
Partial-thicking
1-superficial ( red,painful,blister) heal in 1021 days
2-deep dermal( pale ,painful, yellow) heal in 3
weeks , scarring
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Clinical manifestation
3-Third –degree:
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Full thickness ,require grafts if >1 cm
Avascular and coagulation necrosis
4- fourth – degree:
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Involve underling facia, muscle or bone
Clinical manifestation
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Sever burn:
>15%Body surface
involves face or prineum
2 and 3 –degree burns hands or feet
circumfrential burn of extermity
inhalation injury
Percent of body surface area involved
Each upper extremity 9%
 each lower extremity 18%
 Posterior trunk 18%
 Anterior trunh 18%
 Head 9% and prinium1%
Location is important :
 Face, eyes, ears, feet, prinium, hand ,full
thickness
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treatment
decision is based on :
 Extent of burn(% burn) , body surface (location), type of
burn, associated injure, medical complication
,availability ambulatory management
 Stop the burning process
 Fluid and electrolyte support (systemic copillary
leak)
treatment
Significant burn , Second 24 hr dextrose in0.25
normal bolus 20cc/kg lactated Ringer
 Total fluid is 2-4cc/kg/percent burn/24 hr
(Half in first 8 hr) that equal 1cc/kg/hr of urine
saline
 Colloid therapy is needed if burn >30% bs and
provided after 24 hr with crystalloid
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treatment
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Nutritional support:
( burn produce hypermetabolic response
that sedation and analgesic can decrease)
In critical burn parenteral nutrition
Enteral feeding résumé on 2-3 days
treatment
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Wound care:
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Relief any pressure on cerculation
Covered with sulfadiazin
Graft
Tetanus toxoid in incomplete
immunization
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hospitalization
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Extended of burn > 10% in children
Body surface area involved:
Face ,neck, both hands, both feet ,prineum
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Type of burn; electrical contact ,chemical
 Association injuries;
Soft tissue trauma, fractures,smoke inhalation
head injury .
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hospitalization
Complicating medical problems
Diabetes ,heart disease, pulmonary disease, ulcer
history.
 Social problem.
Suspected child abuse or neglect, self infected
burn, psycologic problems
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Burn Complication
Sepsis ( avoid prophylactic antibiotic)
 Hypovolemia, hypothermia
 laryngeal edema
 carbon monoxide injury
(100% o2,hyper baric o2)
 cardic disfunction
 gasteric ulcer
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Burn Complication
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compartment syndrome
contracture
hyper metabolic state
renal failure
anemia
psychological trauma
pulmonary infiltration,pulmonary edema,
pneumonia,bronchospasm