Module 3.

4:

Shock

Paediatric Emergency Hospital Care

Médecins Sans Frontières

V1.1 June 2017

Objectives

Recognise shock
! Define shock
! Determine the type of shock
! Evaluate the severity of shock
Define shock
Syndrome of “cellular hypoperfusion”

Heart " Tachycardia

" Weak or absent pulse

Skin " CRT >3 seconds

" Cold peripheries

Kidney " Oliguria

Brain " Agitation

" Altered consciousness
Shock – diagnosis:

All three of the following signs:

Cold hands and feet
Weak OR fast (or slow) pulse
CRT > 3 seconds

NB if only 1 or 2 signs present = “circulatory impairment”

Determine the type of shock
Determining the cause of shock

To maintain perfusion you need:

! A pump (the heart)

! Pipes (vessels)

! Fluid (blood)
What happens if the pump fails?

= CARDIOGENIC SHOCK

Myocarditis
Congenital heart disease
Toxins

Consider in any child with evidence of pulmonary congestion

(grunting, tachypnoea, wet cough, hepatomegaly)

Cautious trial of fluids 5 – 10 mL/kg and assess response

What happens if the pipes fail?

= DISTRIBUTIVE SHOCK

Sepsis **
Anaphylaxis
Spinal cord injury

Peripheral vascular dilation and decreased systemic vascular

resistance
Fluids have a limited role
Patient may need adrenaline
What happens if the pipes are empty?

= HYPOVOLAEMIC SHOCK

Gastroenteritis **
Haemorrhage
Severe burns

Common in children
Generally responds well to fluid therapy
Fluid (isotonic - RL or NS)
Blood transfusion
Shock – differential diagnosis

Most common diagnoses in MSF settings are:

Severe dehydration
Sepsis
Severe anaemia
Differential diagnosis – severe dehydration:

Definition of severe dehydration AT LEAST 2 SIGNS:

! Altered level of consciousness (lethargic/ unconscious)
! Sunken eyes
! Unable to drink or drinks poorly
! Skin pinch goes back very slowly (≥2 seconds)
Differential diagnosis – severe dehydration:

Sunken eyes Skin pinch goes back slowly

Differential diagnosis – severe anaemia
Evaluate the severity of shock
Severity of shock
Compensated
Vital organ function (brain + heart) preserved by compensatory
mechanisms – increased systemic vascular resistance, blood
diverted from non essential tissues, increased heart rate
Systolic blood pressure remains normal

Decompensated
Compensatory mechanisms fail and circulatory system no longer
adequate
Blood pressure drops

Irreversible
Point at which death is inevitable, despite treatment
Cardiac arrest
 Severity of shock: a continuum

Compensated Decompensated

Pulse

Respiration
Blood
pressure
AVPU V