Definition and Pathophysiological Keys
Shock is a state of acute circulatory failure that results in inadequate delivery of oxygen and substrates to tissues to meet their metabolic demands. In pediatrics, it is crucial to remember that Children are not small adults.
Fundamental Principle
Hypotension is a sign late and ominous in children. Its main compensatory mechanism is intense peripheral vasoconstriction and tachycardia. Early recognition should be based on signs of tissue hypoperfusion (capillary refill, pulses, mental status, urine output) before blood pressure falls.
Phases of the Shock
Shock is a dynamic process that progresses through several phases if left unattended. Recognizing the current phase is vital to guide the urgency and type of treatment.
Compensated
Compensatory mechanisms maintain normal BP and perfusion of vital organs.
Signs: Tachycardia, cold/pale/mottled skin, capillary refill >2s, weak peripheral pulses, mild oliguria.
Decompensated
Failure of compensatory mechanisms. Hypotension appears.
Signs: Hypotension, altered mental status, tachypnea, metabolic acidosis.
Irreversible
Extensive cellular and organ damage. Resuscitation is usually ineffective.
Signs: Bradycardia, coma, multiple organ failure, imminent arrest.
Crash Classification
Select a type of shock to see its pathophysiology, causes and clinical manifestations. The hemodynamic profile graph will update to show the key characteristics of each type.
Select a crash type to get started.
Typical Hemodynamic Profile
Immediate Management Principles (ABCDE)
A (Airway): Ensure a patent airway.
B (Breathing): Administer oxygen at high flow. Support ventilation if necessary.
C (Circulation): Obtain rapid vascular access (IV/IO). Initiate resuscitation with fluids and/or vasoactive drugs.
D (Disability): Evaluate neurological status. Correct hypoglycemia.
E (Exposure): Complete exposure, temperature control and search for foci (e.g. infection, hemorrhage).
Fluid Resuscitation
Fluid therapy is key, but must be judicious. Use balanced crystalloids (e.g. Lactated Ringer's) over 0.9% Saline.
Hypovolemic/Septic Shock
bowling 10-20mL/kg in 5-20 min. Reevaluate after each bolus. It can be repeated up to 40-60 mL/kg in the first hour if there is a response.
Cardiogenic/Obstructive Shock
CAUTION! Smaller and slower bowling: 5-10mL/kg in 10-20 min. Excess fluid can worsen pulmonary edema.
Vasoactive and Inotropic Drugs
Start if there is no response to fluids (or before in cardiogenic shock). Click on a drug to see details.
Objectives of Resuscitation
The goal is to restore tissue perfusion. Continuously evaluate the response to treatment seeking normalization of these parameters.
State of mind
Normal for age
Heart Rate
Normal for age
Pulses
Strong peripherals
Capillary Filling
< 2 seconds
Fur
hot and dry
Diuresis
> 1 mL/kg/hour
Lactate
in descent
Blood pressure
Normal for age
New Tools: Phoenix Sepsis Score
The Phoenix Sepsis Score is a new tool to identify life-threatening organ dysfunction in children with infection. A score ≥ 2 indicates sepsis.
He septic shock It is defined by cardiovascular dysfunction within this score (≥ 1 cardiovascular point), which includes severe hypotension, lactate > 5 mmol/L, or need for vasoactive medication.
Final Evaluation
Test your knowledge about pediatric shock by answering these 10 questions. Good luck!