HOW TO RECOGNIZE AND

MANAGE SHOCK IN PEDIATRIC

 OUTLINE
• DEFINITION
• Stages of Shock
• Type of Shock
• How to recognize
• How to give initial management
 Definition
• Acute clinical syndrome of circulatory
dysfunction in which there is failure to
deliver sufcient oxygen (DO2) and substrate
to meet metabolic demand (VO2).
Cardiovascular system fails to perfuse tissue adequately

“Disbalance between DO2 and VO2”

DO2
VO2
 SHOCK SYNDROME

Cardiovascular system fails to perfuse tissue adequately

Cardiac Circulatory Volume

pump system
Nutrition & O2
<<<
• Generalized cellular hypoxia (cell starvation)
• Impairment of cellular metabolism
• Tissue damage
• Organ failure
• Death 💀
 Oxygen delivery

Cardiac Output X Arterial Oxygen Content

HR X SV Hb X 1,34 X SaO2

Preload Contractility Afterload

 OUTLINE
• Definition
• STAGES OF SHOCK
• Type of Shock
• How to recognize
• How to give initial management
 Stages of Shock

Initial stage

Compensatory stage

Progressive/
Decompensated
stage

Irreversible/
Refractory stage
 Compensatory Mechanism

Sympatetic nervous system and Adrenal

response
(Neurohormonal)

• HR ↑
• Contractility ↑ • Anterior pituitary gland ACTH 
• Vasoconstriction  afterload ↑ cortex adrenal  Cortisol
• Preload ↑
• Renal perfussion ↓ • Glucocorticoid effect
• RAA release: Sodium and water
retention • Blood glucose ↑
 Compensatory Mechanism

Sympatetic nervous system and ADH

(Neurohormonal)

Osmoreseptor (hypothalamus) stimulated  posterior

pituitary gland  ADH/vasopressin release

Vasopressor Renal tubules:

effect Retain water
 Signs of Compensatory Failure

• Blood flow to the tissue ↓  Cellular hypoxia

• Anaerobic metabolism begins Decomp ensated
• Acidosis
• Cell swelling, mitochondrial disruption, cell
death

Low perfusion persists

Cell death >>>

Irreversible state!!!
Multiple organ failure

Death
Types of Shock
 Emergency Assessment
1. First observational assessment or Quick look
2. Primary physiological Assessment : ABCDE
approach
3. Secondary clinical assessment: medical history
4. Tertiary complementary assessment: lab, imaging
 Types of
Shock

Blood Blood
VOLUME Blood PUMP VESSELS
problem problem problem
Hypovolemic Distributive shock
shock Cardiogenic shock
“Empty Tank”

External Internal
fluid loss fluid loss

• Fluid loss:
dehydration • Vascular
• Blood loss permeability ⬆
• Oncotic pressure
↓
Paediatric Assessment Triangle: a quick look

Body Colour

Circulation
Paediatric Assessment Triangle: a quick look

• Pallor
• Mottling
• Cyanosis

Body Colour

Circulation
 Renjatan

N N

N
Gagal napas/sirkulasi

N /

N
 Circulation
• Pulse heart rate
• Peripheral perfusion
– Perfusi kulit (suhu, akral, CRT, warna)
• Blood Pressure
• Pulses volume
– Perabaan nadi
• Preload
Nilai normal berdasarkan usia
Kriteria hipotensi sesuai usia
 Tatalaksana

1. ABC
2. Vascular access
3. Fluid resucitation
4. Drugs (inotropic & vasoactive)

Diagnosis dan tata laksana sepsis pada anak. Badan Penerbit IDAI
2016
 DO2 :
Curah Jantung x Oksigen Darah Arteri

Frekuensi x Isi Hb x 1,34 x SaO2 + 0,003 x PaO2

Sekuncup

Preloa afterloa
d Kontraktilitad
Transfus pH O2
s
i PCO MA
2
P
Cairan Vasoakti Suhu

Inotropi f
k
 Resusitasi Cairan

❖ Jenis cairan: kristaloid atau koloid

❖ Jumlah cairan: 20 cc/kgBB secara bolus cepat selama 5-10

menit (menggunakan push and pull atau pressure bag)

❖ Dapat diulang dengan menilai respons terhadap cairan

(fluid responsiveness).

❖ Resusitasi cairan dihentikan bila:

❖ Target resusitasi tercapai
❖ Bila terjadi refrakter cairan
❖ Bila muncul tanda overload cairan

Diagnosis dan tata laksana sepsis pada anak. Badan Penerbit IDAI
2016
 Menilai respons terhadap cairan
(Fluid responsiveness)

1. Fluid challenge
2. Passive leg raising (PLR)
3. Ultrasonografi
• Pengukuran diameter IVC
• USCOM
4. Arterial waveform
5. Pulse contour analysis
 Fuid Challange

 Pemberian sejumlah cairan secara cepat untuk menilai status

hemodinamik terutama preload (fluid responsiveness).
 Cairan apa yang dipakai?  kristaloid
 Berapa banyak?  10 – 15 ml/kgBB
 Berapa lama?  10 menit
 Mini fluid challenge? 3 ml/kgBB dalam 2 menit
 Harus dilakukan Reassessment

 USCOM/IVC? …
 Klinis
 Passive Leg Raising/ PLR

1. Posisikan badan 45◦

dari bed
2. Datarkan badan, angkat
tungkai bawah 45◦
3. Nilai efek PLR
4. Lakukan monitoring
hemodinamik kontinyu.
5. Reassessment

Pada anak : Hanya bisa

dilakukan pada usia > 5
tahun
 Target Resusitasi Cairan
Klinis
❖ Denyut Jantung normal

❖ Waktu pengisian kapiler < 2 detik

❖ Ekstremitas hangat
❖ Produksi urine > 1 ml/kg/jam

❖ Kesadaran baik

❖ Kualitas nadi normal

❖ Tekanan Darah normal
Hemodinamik Bukan Parameter
❖ Inotropy index TUNGGAL!!!!
❖ SVI

❖ CI

❖ SVRI

❖ ScvO2

Laboratorium
❖ Kadar laktat ≤ 1.6
 Tanda overload cairan

❖ Pembesaran hati akut

❖ Ronkhi basah
❖ Peningkatan upaya
napas
❖ ↑Tekanan vena Jugularis
❖ Foto toraks
❖ Teknik lainnya  IVC
 Volume expansion will increase stroke volume
only if ventricles are preload-dependent !!!!

preload-
S
independence
t
r
o
k
e
V
o
l preload-dependence :
u Every increasing preload will increase Stroke
m Volume

e Every increasing preload by volume

loading

Ventricular preload
 normal heart

S
t
r
o preload-
k dependence
e
V failing
o heart
l
u preload-
m

.
independence

Ventricular preload
 FRANK STARLING`S LAW
5
-Simpatomimetik
POSITIVE - Glikosida
INOTROPY - Xantin
4
- Glukagon
D

3
C
-Hipoksemia
B
2 - Asidosis
NEGATIVE - Hipoglikemia
INOTROPY - Intoksikasi obat
1
A - Endotoksemia
VOLUME INFUSION

0 5 10
 Foto Toraks Gagal Jantung Kongestif

1.Redistribusi vaskular paru

2.Edema interstitial
3.Edema alveolar
 Insufisiensi adrenal
Pasien tidak respons terhadap epinefrin dan NE

Pikirkan insufisiensi adrenal

❖ Faktor risiko :

❖ Paparan steroid sebelumnya

❖ Pasien dengan purpura fulminan

❖ Pasien dengan penyakit sistem syaraf pusat

❖ Terapi :

❖ Pada sakit kritis : hidrokortison 2 mg/kgBB dalam 4 dosis terbagi atau 0,18 mg/kgBB/mnt
selama 7 hari  target kortisol 30 mg/dL

❖ Pada syok hidrokortison 50 mg/kgBB dilanjutkan infus kontinyu selama 24 janm dengan dosis
0,18 mg/kgBB/mnt
 Catatan Kunci

❖ Syok terjadi karena ketidakseimbangan VO2 dan DO2

❖ Empat tipe syok sesuai patofisiologinya adalah
hipovolemik, kardiogenik, distributif dan obstruktif
❖ Target resusitasi cairan adalah perfusi yang baik dan
parameter hemodinamik normal sesuai usia
❖ Hindari pemberian cairan berlebihan dengan tanda gagal
jantung
❖ Inotropik digunakan pada gangguan kontraktilitas