APPROACH TO A PATIENT WITH

SHOCK

By AIMEN MUSTAFA
 Definition
Shock is a life-threatening state that occurs when
oxygen and nutrient delivery are insufficient to
meet tissue metabolic demands.

SUPPLY < DEMAND

Oxygen delivery < Oxygen Consumption
 Pathophysiology
OXYGEN
DELIVERY (DO2)

ARTERIAL CONTENT OF
CARDIAC OUTPUT (CO)
02 (Ca02)

Stroke volume
HEART RATE
(SV)
•HAEMOGLOBIN
•OXYGEN SATURATION
•AUTONOMIC (SaO2),
•PRELOAD NERVOUS • PARTIAL PRESSURE
•AFTERLOAD SYSTEM OF OXYGEN (PaO2)
•CONTRACTILITY •CARDIAC
•LUSITROPY CONDUCTION
SYSTEM.
 STAGES OF SHOCK:
• COMPENSATED SHOCK:
▫ Maintains end organ perfusion
▫ BP is maintained usually by ↑ HR

• HYPOTENSIVE (DECOMPENSATED SHOCK)

▫ Decreases micro-vascular perfusion
▫ Sign/symptoms of end organ dysfunction

• IRREVERVISBLE SHOCK
▫ Progressive end-organ dysfunction
▫ Cellular acidosis results in cell death
• It is important to recognize that oxygen is not
distributed uniformly to the body. Modulation of
systemic vascular resistance (SVR) in different
vascular beds is one of the body’s primary
compensatory mechanisms to shunt blood
preferentially to vital organs such as the heart
and brain.
• In this way, an increase in SVR may maintain a
normal blood pressure even in the face of
inadequate oxygen delivery. In other words,
hypotension need not be present for a child to be
in shock.
Blood Pressure and Volume

% blood loss % BP
25% Normal
50% 60%

•BP drops quickly after

reaching 50% blood loss
•CO follows BP closely

6
• CO and BP maintained well up to 25% of the
decrease in blood volume ---compensated shock.
Compensation by slight increase in vascular
resistance to maintain blood pressure
• CO and BP drop abruptly at 30% of decrease in
blood volume ----Uncompensated shock
• >50% volume loss ---- irreversible shock
TYPES OF SHOCK
TYPES PATHOPHYSIOLOGY SIGNS & SYMPTOMS

Hypovolemic
TYPES OF SHOCK
↓ PRELOAD: ↓CO, ↑ SVR,
intravascular volume loss
Tachycardia, tachypnea,
signs of poor perfusion like
↓ pulses, delayed cap refill,
dry skin, sunken eyes,
oliguria, cold extremities.
Distributive ↓ AFTERLOAD (SVR)

Anaphylactic ↑ CO, ↓ SVR Angioedema, low BP,

wheezing, resp. distress
Spinal Normal CO, ↓ SVR Low BP without
tachycardia; paralysis, h/o
trauma
Cardiogenic ↓ CO, variable SVR Normal to ↑ HR, ↓ pulses,
delayed CR, JVD, murmur
or gallop, hepatomegaly
Septic Variable Explained later.
 Hypovolemic shock
• Hypovolemic shock is the most common form of
shock occurring in children around the world.
• Usually of two types :
o Hemorrhagic shock
o Non hemorrhagic shock

• Diarrheal illnesses are the cause in most of these

patients. Some other causes in non hemorrhagic
shock include thermal injury, and inappropriate
diuretic use.
 Hypovolemic shock
• Signs and symptoms of hypovolemic shock
include
Tachycardia,
Tachypnea, and
Signs of poor perfusion, including cool
extremities, weak peripheral pulses, sluggish
capillary refill, skin tenting, and dry mucous
membranes.
• Orthostatic hypotension may be an early sign.
 Cardiogenic shock:
• Cardiogenic shock refers to failure of the heart
as a pump, resulting in decreased cardiac
output.
• This failure may be due to
Arrhythmias
Volume overload
Diastolic dysfunction.
Depressed myocardial contractility
 Cardiogenic shock:
• Infants and children who have cardiogenic shock
often present with :

Lethargy.
Poor feeding.
Tachycardia.
Tachypnea.
Pale and have cold extremities.
Barely palpable pulses.
 Cardiogenic shock:

• Initially, it may be impossible to differentiate

cardiogenic shock from septic shock. Findings
more specific to cardiogenic shock include a
gallop rhythm, rales, jugular venous distension,
and hepatomegaly.
• Chest radiography reveals cardiomegaly and
pulmonary venous congestion.
Distributive or neurogenic shock:

• Distributive shock is caused by derangements in

vascular tone that lead to end-organ
hypoperfusion.
• This outcome is seen with anaphylaxis as well as
spinal cord trauma and spinal or epidural
anesthesia can cause widespread vasoplegia due
to loss of sympathetic tone sometimes referred
to as neurogenic shock.
Distributive or neurogenic shock:
VASODILATION

VENOUS POOLING

Mal-distribution of DECREASED AFTER-

regional blood flow LOAD
Distributive or neurogenic shock:

• Anaphylaxis is a severe, acute and potentially

life-threatening medical condition caused by the
systemic release of mediators from mast cells
and basophils, often in response to an allergen
Signs and symptoms of anaphylaxis
System Signs and symptoms

General/CNS Fussiness, irritability, drowsiness, lethargy,

reduced level of consciousness, somnolence

Skin Urticaria, pruritus, angioedema, flushing

Upper airway Stridor, hoarseness, oropharyngeal or laryngeal

edema, uvular edema, swollen lips/tongue,
sneezing, rhinorrhea, upper airway obstruction
Lower airway Coughing, dyspnea, bronchospasm, tachypnea,
respiratory arrest
Cardiovascular Tachycardia, hypotension, dizziness, syncope,
arrhythmias, diaphoresis, pallor, cyanosis,
cardiac arrest
Gastrointestinal Nausea, vomiting, diarrhea, abdominal pain
 Clinical criteria for diagnosing anaphylaxis
Anaphylaxis is highly likely when any one of the following three criteria are fulfilled:

1. Acute onset of an illness with involvement of the skin, mucosal tissue or both and
at least one of the following:
a. Respiratory compromise.
b. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia
syncope or incontinence)

2. Two or more of the following that occur rapidly after exposure to a likely allergen
for that patient:
a. Involvement of the skin-mucosal tissue
b. Respiratory compromise
c. Reduced BP or associated symptoms of end-organ dysfunction
d. Persistent gastrointestinal symptoms.

3. Reduced BP after exposure to a known allergen for that patient

a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in
systolic BP*
 Septic shock

• SIRS (systemic inflammatory response syndrome)

o Widespread inflammation due to infection, trauma,

burns, etc.
o Criteria – requires 2 of the followings
▫ Core temp >38.5˚C or <36˚C
▫ Tachycardia (or bradycardia in infants)
▫ Tachypnea
▫ Elevated or depressed WBC or >10% bands
• Sepsis
SIRS in the presence of or as a result of suspected
or proven infection (evidence of infection includes
positive findings on clinical examination, imaging,
or laboratory tests)

• Severe Sepsis
Sepsis plus one of the following: cardiovascular
organ dysfunction OR acute respiratory distress
syndrome or two or more other organ
dysfunctions.
• Septic Shock

In a child with sepsis presence of:

Hypotension or need for vasoactive drug to
maintain BP above fifth centile or Signs of
hypoperfusion—any three of the following:

• tachycardia
• decreased pulse volume
• urine output <1 ml/kg/h
• , capillary refilling time >3 s
• core to peripheral temperature gap >3 °C
Clinical presentation of septic shock

Warm shock Cold shock

Peripheries Warm, flushed Cold, clammy,

cyanotic
Capillary refill <2sec >2sec

Pulse Bounding Weak, feeble

Heart rate Tachycardia Tachycardia or

bradycardia
Blood pressure Relatively hypotension
maintained
Pulse pressure Widened Narrowed
 Management

• STEP 1: 0–5 min:

o Recognize depressed mental status and

decreased perfusion by rapid cardiopulmonary
assessment.
o Begin high flow oxygen
o Establish intravenous/intraosseous access.
• STEP II: 5–40 min:

o Initial fluid resuscitation: Rapid infusion of 20 mL/kg

isotonic saline each, up to 60 mL/kg, titrated toward
achievement of therapeutic goals of shock resolution
or unless rales or hepatomegaly develop.
o Fluid therapy by peripheral or intraosseous access
should be initiated while adequate control of airway,
and breathing is being accomplished.
o A second peripheral IV line or central line should be
established if feasible
o Antibiotics should be started (third generation
cephalosporin and aminoglycosides)
o Hypoglycemia and hypocalcemia should be treated.
• STEP III: 40–60 min:

o Recognize Fluid Refractory Shock: Begin

inotrope by intravenous or intraosseous (IO)
route; Dopamine up to 10 μg/kg/min.
o Obtain central venous access and airway if
needed and feasible
• STEP IV: 60 min and Beyond

o Recognize dopamine resistant shock.

o Transfer to PICU.
o If possible, monitor CVP, echocardiography, mean
arterial pressure.
o Titrate fluids and vasoactive drugs to resolve shock
based on CVP, echocardiography to achieve
therapeutic goals.
o Reverse cold shock-resistant to dopamine (normal or
low blood pressure) titrate central epinephrine (0.05–
0.3 μg/kg/min)) (maximum dose 1
microgram/kg/min)
o Reverse warm shock with wide pulse pressure and/or
low blood pressure by titrating central
norepinephrine
o Begin hydrocortisone (50 mg/m2/24 h) if child is at
risk for absolute adrenal insufficiency
Therapeutic endpoint of resuscitation
of septic shock
1. Normalization of the heart rate

2. Capillary refill of <2sec

3. Well felt dorsalis pedis pulses with no differential

between peripheral and central pulses
4. Warm extremities

5. Normal range of systolic pressure and pulse pressure

6. Urine output>1ml/kg/hour

7. Return to baseline mental status tone and posture

8. Normal range respiratory rate

 CINICAL SCNERIOS

1- A 9-month-old girl presents to the emergency

department (ED) with a 4-day history of
profuse diarrhea and poor oral intake. On
physical examination, she appears irritable.
Her respiratory rate (RR) is 70 breaths/min,
heart rate (HR) is 180 beats/min, and blood
pressure (BP) is 80/50 mm Hg. She has cool,
mottled extremities, with sluggish capillary
refill and weak peripheral pulses.
2- A 17-year-old boy presents to the ED with a 1-
day history of headache, general malaise, and
fevers. On physical examination, he appears
confused. He has a temperature of 39.9°C,Hrof
120 beats/min, and BP of 85/28 mm Hg. His
skin appears plethoric. His extremities are hot,
with flash capillary refill and bounding pulses.
3- A 2-week-old boy presents to the ED with a 1-
day history of poor feeding. On physical
examination, he is difficult to arouse. His RR is
80 breaths/min, HR is 220 beats/min, and BP
is undetectable. He appears cyanotic and has
cold extremities and a 5-second capillary refill
time.
Answers ??