WACHEMO UNIVERSITY

FACULITY OF MEDICINE AND HEALTH

SCIENCE
DEPARTMENT OF PUBLIC HEALTH OFFICER(3rd
YR)

1
2 INTRODUCTION

Total body water

 At birth – 78% of body weight
 > one year – 55-60% of body weight
 Fluid compartments
 ICF and ECF
 ECF higher than ICF in the fetus
 ECF volume drops after birth
3 Total body water

 Adult ICF –ECF ratio attained at one year

 ECF – 20-25% of body wt.
 Plasma water 5%
 Interstitial water 15%
 ICF 30-40% of body wt.
 4
TOTAL BODY WATER (TBW)
ü Term baby: 75-80%

ü At 3 months: 65-70%

ü At the age of one year, TBW equals the adult level: 60

%
ü 60% of BW in male
ü 50 % of BW in female

Lean individual have a greater water vol.than obese ones

(20-30%more).
 5

Sources of body fluids

Exogenous: ingested /drank fluids (2-3L/d)

: Water in the solid food (800-1000ml/d)

Endogenous: from oxidation of food (200-300ml/d)

 6

Fluid loss could be:

Lung- with expired air (450ml/d)

- Loss increase with increase in RR

Skin - with perspiration (600-1000ml/d)

-Loss increase with fever (by 10-12% each oc)

Faces-80-150ml/d

Urine:- ranges from 600-2500ml/d

- approx.60 %( 400ml/d) are required to excrete
metabolic products.
-mainly under ADH control.
7 Definition
 DEHYDRATION: from Greek word hydro
(water) and the Latin prefix de (Deprivation,
removal, separation)

 is a condition that occurs when the loss of body

fluids, mostly water, exceeds the amount that is
taken in.

 with dehydration, more water is moving out of our

cells and bodies then what we take in through
drinking.
8 Causes
 In most cases, volume depletion in children is
from fluid losses from vomiting or diarrhea.
 Vomiting may be caused by any of the following
systems or processes:
 CNS (eg, infections, space-occupying lesions)
 GI (eg, gastroenteritis, obstruction, hepatitis, liver
failure, appendicitis, peritonitis, intussusception,
volvulus, pyloric stenosis, toxicity [ingestion,
overdose, drug effects])
9 Cont…
 Endocrine (eg, diabetic ketoacidosis
[DKA], congenital adrenal hypoplasia,
Addisonian crisis)
 Renal (eg, infection, pyelonephritis, renal
failure, renal tubular acidosis)
 Psychiatric (eg, psychogenic vomiting) -
This is not seen in infants and is rare in
children compared with adults.
 10

Diarrhea may be caused by any of the following systems or

processes:

-GI (e.g., gastroenteritis, malabsorption, intussusception,

irritable bowel, inflammatory bowel disease, short gut
syndrome)
-Endocrine (eg, thyrotoxicosis, congenital adrenal
hypoplasia, Addisonian crisis, diabetic enteropathy)
Psychiatric (eg, anxiety)
11
Volume depletion not caused by vomiting or diarrhea
may be divided into two
Renal cause;
Include use of diuretics, renal tubular acidosis, and
renal failure (eg, trauma, obstruction, salt-wasting
nephritis) and effects of diabetes insipidus,
hypothyroidism, and adrenal insufficient
Extrarenal causes
Include third-space extravasation of intravascular
fluid (eg, pancreatitis, peritonitis, sepsis, heart
failure); insensible losses from fever, sweating, burns,
or pulmonary processes; poor oral intake; and
 Types of dehydration
Isotonic 70-80% Hypertonic Hypotonic
(isonatremic) (hypernatremic) (hyponatremic)
Loses H2O = Na H2O > Na H2O < Na

Plasma Normal Increase Decrease

osmolality (> 295) (<275)
Serum Na Normal Increase Decrease
(>150) (<130)
Causes Boiled skimmed Bacillary dysentry,
milk, fever, cholera, oral intake of
hyperventlation low electolite fluids
Thirst ++ +++ +/-
Skin turgor ++ Not lost +++
Mental state Irritable/lethargic Very irritable Lethargy/coma

Shock In severe cases Uncommon Common 12

 13
Degree of Dehydration
Factors Mild < 5% Moderate Severe >10%
5-10%
General Condition Well, alert Restless, thirsty, Drowsy, cold
irritable extremities, lethargic
Eyes Normal Sunken Very sunken, dry

Anterior fontanelle Normal depressed Very depressed

Tears Present Absent Absent

Mouth + tongue Moist Sticky Dry

Skin turgor Slightly decrease Decreased Very decreased

**Pulse (N=110- Slightly increase Rapid, weak Rapid, sometime

impalpable
120 beat/min)
**BP (N=90/60 Normal Deceased Deceased, may be
unrecordable
mm Hg)
Respiratory rate Slightly increased Increased Deep, rapid

Urine output Normal Reduced Markedly reduced

Clinical signs and symptoms
14
15 CONT…

 Mild dehydration (<5% in an infant; <3% in an older child or

adult):
- normal or increased pulse
- decreased urine output
- Thirsty
- normal physical findings
16 CONT…
 Moderate dehydration (5–10% in an
infant; 3–6% in an older child or adult):
 tachycardia
 little or no urine output
 irritable/lethargic
 sunken eyes and fontanel
 decreased tears
 dry mucous membranes
 mild delay in elasticity (skin turgor )
 delayed capillary refill (>1.5 sec)
17 CONT…
 Severe dehydration (>10% in an
infant; >6% in an older child or adult):
 rapid and weak or absent peripheral pulses
 decreased blood pressure , no urine output
 very sunken eyes and fontanel , no tears
 parched mucous membranes
 delayed elasticity (poor skin turgor)
 very delayed capillary refill (>3 sec)
 cold and mottled limp
 depressed consciousness
18 COMPLICATIONS

 Heat injury
 swelling of the brain
 cerebral edema
 seizure
 low blood volume shock
 kidney failure
 coma and death
19 MANAGEMENT OF
DEHYDRATION
 No DHN– Mx plan A
 Treat diarrhea at home:
 Rules of 3 ‘Fs’
1. Give extra FLUID
2. Continue FEEDING
3. When to come for FOLLOW UP
20 CONT…
 Fluid – in addition to the usual fluid intake
give ORS: 10ml/kg
OR
50-100ml for those below 2yrs per bowel

100-200ml for children > 2yrs motion

Other fluids; breast milk, food-based

fluids(soup,rice water,yogurt) or clean water
21 CONT…
 Feeding- frequent breast feeding
-cow’s milk or formula
- continue other foods if he started
 Return/follow up-see him in 2days
- come back immediately if the child
becomes sick(unable to
drink,sicker,fever,dysentery)
22 CONT…
B. Some DHN– plan B, loss is estimated to
be 5%(average)
Treat with ORS:
Volume is 75ml/kg
Give over 4hrs
Continue breast feeding
If vomiting, wait for 10minutes
After 4hrs, reassess and classify DHN
23 CONT…
c. Severe DHN-
 treatment plan C-loss estimated to be 10%
of body weight
 Start IV immediately
 Ringer’s lactate or NS
 Volume is 100ml/kg
 24
Infants(below 12 months of 1st give 30 ml/kg over one Then give 70ml/kg over five
age) hour hours

Children >12 months of age Over 30 minutes Over two and half hour

1st After the 30ml/kg:if no response, repeat the same amount(not subtracted from 70ml/kg)
 Pediatric Shock
Out lines
25

Introduction
Classification &Types of shock
Shock in mal nourished children
Clinical presentation
Evaluation
 investigation
 Management
02/03/2006
26
Introduction

 Millions of children die of shock due to

various etiologies each year.
 several different forms from hypovolemia
to sever infection cause shock.
 This presentation focuses on the
definition of different types of shock seen
in children and treatment strategies based
on recent literature.
02/03/2006
27
Definition

 Shock is a syndrome that results from

inadequate oxygen delivery to meet
metabolic demands
 Oxygen delivery (DO2 ) is less than
Oxygen Consumption (< VO2)

 Untreated this leads to metabolic acidosis,

organ dysfunction and death
02/03/2006
Oxygen Delivery
28

 Oxygen delivery = Cardiac Output x Arterial

Oxygen Content
(DO2 = CO x CaO2)
 Cardiac Output = Heart Rate x Stroke Volume
(CO = HR x SV)
– SV determined by preload, afterload and
contractility
 Art Oxygen Content = Oxygen content of the
RBC + the oxygen dissolved in plasma

02/03/2006
29

02/03/2006
Epidemiology
30

 The highest mortality rates are observed in children

under 5 years in developing countries.
 The leading causes of shock in children younger than
5 years of age are
- pneumonia 19%
-Dirrhoea 18%
-Malaria 8%
-Neonatal pneumonia or sepsis 10% and asphyxia at
birth 1% .
02/03/2006
Classification of Shock
31
COMPENSATED
– blood flow is normal or increased and may be
maldistributed
– vital organ function is maintained

UNCOMPENSATED
– microvascular perfusion is compromised
– significant reductions in effective circulating
volume

IRREVERSIBLE
– inadequate perfusion of vital organs
– irreparable damage 02/03/2006

–
32
TYPES OF SHOCK

 HYPOVOLEMIC SHOCK

 SEPTIC SHOCK

 CARDIOGENIC SHOCK

 DISTIRBUTIVE SHOCK

 OBSTRACTIVE SHOCK

 DISOCIATIVE SHOCK 02/03/2006

33
1.Hypovolemic Shock
 Most common form of shock world-wide
 Results in
 decreased circulating blood volume
 decrease in preload
 decreased stroke volume and
 resultant decrease in cardiac output
 Etiology: Hemorrhage, renal and/or GI fluid
losses, capillary leak syndromes

02/03/2006
 34

Con…
 Clinically, history of vomiting/diarrhea or
trauma/blood loss
 Signs of dehydration
 dry mucous membranes
 absent tears
 decreased skin turgor
 Hypotension, tachycardia without signs of congestive
heart failure

02/03/2006
35

2.Septic shock
 Still remains significant cause of
morbidity and mortality
 5-30% of paediatric patients with sepsis
will develop septic shock.
 Mortality rates in septic shock are 20-30%

02/03/2006
 36

Con…
septic shock includes

 Systemic Inflammatory Response Syndrome

 Infection
 Sepsis
 Severe Sepsis
 Septic Shock

02/03/2006
37
Systemic Inflammatory
Response Syndrome
Presence of 2 of the following criteria:
 Core Temp >38.5 or < 36 degrees
 HR = persitant elevation over 0.5-4hrs
 If < 1yr old: bradycardia HR < 10th centile
for age
 RR > above normal for age
 Leucocyte abnormality/> 10% from
normal/
02/03/2006
SEPSIS
38

 SIRS in presence of suspected or proven infection

Severe Sepsis
 Sepsis + one of the following
 CV organ dysfunction
 ARDS
 2 or more organ dysfunction

Septic Shock
 Sepsis + CV organ dysfunction
02/03/2006
Septic Shock: “Warm Shock”
39

 Early
 compensated, hyperdynamic state
 Clinical signs
 Warm extremities with bounding
pulses, tachycardia, tachypnea,
confusion.
 Physiologic parameters
 widened pulse pressure
 increased cardiac ouptut and mixed
venous saturation 02/03/2006

 decreased systemic vascular resistance.

 Septic Shock: “Cold Shock’
40

 Late
 uncompensated stage with drop in cardiac
output.
 Clinical signs
Cyanosis, cold and clammy skin, rapid
thready pulses, shallow respirations.
 Physiologic parameters
Decreased mixed venous sats, cardiac output
and CVP, increased SVR, thrombocytopenia,
oliguria, myocardial dysfunction.
 Biochemical abnormalities
Metabolic acidosis 02/03/2006
hypoxia.
 41
Con…
 Cold Shock rapidly progresses to multi organ system
failure or death if untreated
 Multi-Organ System Failure:
 Coma
 ARDS
 CHF
 Renal Failure
 More organ systems involved, worse the prognosis

02/03/2006
 Cold Shock Warm Shock

42

HR Tachycardia Tachycardia

Peripheries Cool Warm

Pulses Difficult to palpate Bounding

Skin Mottled, pale Flushed

Capillary refill Prolonged Blushing

Mental state Altered Altered

Urine Oliguria Oliguria 02/03/2006

43
3.Cardiogenic shock

 Low CO and high systemic vascular

resistance
 Result of primary cardiac dysfunction:
 A compensatory increase in SVR occurs
to maintain vital organ function
 Subsequentincrease in LV afterload, LV
work, and cardiac oxygen consumption
 CO decreases and ultimately results in
volume retention, pulmonary edema, 02/03/2006

and RV failure
44
Con…
 Etiology:
– Dysrhythmias
– Infection (myocarditis)
– Metabolic
– Obstructive
– Congenital heart disease
– Trauma

02/03/2006
45
Con…
 Differentiation from other types of shock:
– History
– Exam:
 Gallop rhythm
 Murmur
 Rales
– CXR:
Enlarged heart, pulmonary venous
congestion
02/03/2006
46
4.Distributive Shock
 Due to an abnormality in vascular tone leading to
peripheral pooling of blood with a relative
hypovolemia.
 Etiology
– Anaphylaxis
– Neurologic injury
– Early sepsis

02/03/2006
47
5.Obstructive Shock
 Mechanical obstruction to ventricular outflow
 Etiology: Congenital heart disease
 massive pulmonary embolism
 tension pneumothorax
 cardiac tamponade
 Inadequate C.O. in the face of adequate
preload and contractility

02/03/2006
 48

6.Dissociative Shock
 Inability of Hemoglobin molecule to give up the
oxygen to tissues
 Etiology:
• Carbon Monoxide poisonin,
• methemoglobinemia
 Tissue perfusion is adequate, but oxygen release to
tissue is abnormal

02/03/2006
 49
Shock in malnourished
children
• Difficult to assess in malnourished children
• IV fluids are dangerous, especially in a situation with
no effective monitoring
• Reliable Signs: Watery Diarrhea; Thirst (absent in
severe dehydration); Sunken eyes (only if developed
recently); low urine output;

• Unreliable Signs in Malnurished Child: Elastic skin

and dry mucous membranes are not reliable in
severely malnourished children 02/03/2006
Other causes of shock in severely
50

malnourished child
 Toxic shock
 Septic shock
 Cardiogenic shock

02/03/2006
51
Compensatory Mechanisms

 Baroreceptors-
- In aortic arch and carotid sinus
- low MAP cause vasoconstriction
- increases BP, CO and HR
 Chemoreceptors-
-Respond to cellular acidosis
results in vasoconstriction and respiratory
stimulation 02/03/2006
52
Con….

 Renin Angiotensin- Decreased renal

perfusion leads to angiotensin causing
vasoconstriction and aldosterone causing
salt and water retentions
 Humoral Responses-Catecholamines
 Autotransfusion-Reabsorption of
interstitial fluid

02/03/2006
 Renin
53
angiotensin – aldosterone
system
decreased cardiac out put

decreased renal blood flow

RAA path way activated

Enhance Na and water retention

Increase fluid volume/BP increasing/

02/03/2006
54

02/03/2006
55
Initial Evaluation
By history taking
 Past medical history
– heart disease

– surgeries

– steroid use

– medical problems

 Brief history of present illness

– exposures

– onset

02/03/2006
56

BY Physical Exam

 Neurological: Fluctuating mental status,

sunken fontanel
 Skin and extremities: Cool, pallor, mottling,
cyanosis, poor cap refill, weak pulses, poor
muscle tone.
 Cardio-pulmonary: Hyperpnea, tachycardia.
 Renal: Scant, concentrated urine

02/03/2006
 Laboratory/ Investigation/
57

– ABG/arterial blood gas/

– Blood sugar
– Electrolytes
– CBC
– PT/PTT/partial thrombopalstin time/
– Cultures

02/03/2006
58
Management-General
 Goal: increase oxygen delivery and decrease
oxygen demand:
For all children:
○ Oxygen
○ Fluid
○ Temperature control
○ Correct metabolic abnormalities
Depending on suspected cause:
○ Antibiotics
○ Mechanical Ventilation 02/03/2006
 Con…
59  Airway
 If not protected or unable to be maintained,
intubate.
 Breathing
 Always give 100% oxygen to start
 Sat monitor
 Circulation
 Establish IV access rapidly
 CR monitor and frequent BP

02/03/2006
60
Management-Volume Expansion

 Optimize preload
 Normal saline (NS) or lactated ringer’s (RL)
 Except for myocardial failure use
10-20ml/kg every 2-10 minutes. Reasses
after every bolus.
 At 60ml/kg consider: ongoing losses,
adrenal insufficiency, intestinal ischemia,
obstructive shock. Get CXR.

02/03/2006
61
References

 Nelson’s Textbook of
Pediatrics/18th ed.n/
 Protocol for the management of
severe acute malnutrition 2007
 upto date 21.13

02/03/2006
62

10Q
10Q
10Q
02/03/2006