2 - Shock Overview Flashcards
What are the two types of shock you should be able to differentiate between?
compensated and hypotensive
True or false?
Shock can be present with or without hypotension?
true
Shock that results from inadequate blood volume or oxygen carrying capacity is called
hypovolemic shock, including hemorrhagic shock
Shock that results from inappropriate distribution of blood volume and flow is called what?
distributive shock
Shock that results from impaired cardiac contractility is called what?
cardiogenic shock
Shock that results from obstructed blood flow is called what?
obstructive shock
In this clinical condition, there are clinical signs of inadequate tissue perfusion, but the blood pressure is in the normal range.
Compensated shock
What are some signs of compensated shock referring to the organs; skin 4, heart 1, pulses 2, kidneys 1, intestines 2, and brain 3
- heart - tachycardia
- skin - cold, pale, mottled, diaphoretic
- Pulses - weak, narrow pulse pressure
- kidneys - oliguria
- Intestines - vomiting, ileus
- brain - AMS, anxiety/restless, disorientation
Another name for hypotensive shock is what
decompensated shock
What is the formula to determine is hypotension is present in a child?
70 mmHg + (childs age x 2)
How long can it take for compensated shock to progress into decompensated shock
it can take a matter of hours
How long can it take for decompensated shock to progress into cardiac arrest?
potentially minutes
What are some possible causes of hypovolemic shock?
(5)
- gastroenteritis (vomiting),
- burns,
- hemorrhage,
- inadequate fluid intake,
- osmotic diuresis (DKA)
What are some possible causes of cardiogenic shock ?
(4)
- congenital heart disease,
- myocarditis,
- cardiomyopathy,
- arrhythmia
What are some possible causes of distributive shock?
(3)
- sepsis,
- anaphylaxis,
- spinal cord injury
What are some possible causes of Obstructive shock?
(4)
- tension pneumothorax,
- cardiac tamponade,
- pulmonary embolism,
- constriction of the ductus arteriosus
______ shock refers to the clinical state of characterized by reduced SVR leading to _______ of blood volume and blood flow, such as with septic, anaphylactic, and neurogenic shock
- distributive shock
- maldistribution
What are three different types of distributive shock?
- septic shock
- anaphylactic shock
- neurogenic shock
The most common type of of distributive shock is
septic shock
Neurogenic shock is also known as _____ shock
spinal
What are the three primary signs of neurogenic shock
- hypotension with a wide pulse pressure
- normal heart rate or bradycardia
- hypothermia
This type of shock is the result of abnormal cardiac function or pump failure
cardiogenic shock
_____ shock refers to conditions that physically impair blood flow by limiting venous return to the heart or limit the pumping of blood from the heart
obstructive shock
What are 4 common causes in pediatrics that can cause obstructive shock?
- pericardial tamponade
- tension pneumothorax
- ductal-dependent congenital heart defects
- massive pulmonary embolism
Name 5 goals in the treatment of shock
- Improve O2 delivery
- Balance tissue perfusion &metabolic demand
- Reverse perfusion abnormalities
- Support organ function
- Prevent progression into cardiac arrest
Warning signs that indicate progression from compensated shock to hypotensive shock include (4)
- Narrowing pulse pressure
- Hypotension
- Decreasing LOC
- Weakening central pulses
Name 4 things that can result in hyperkalemia
- renal dysfunction
- cell death
- excess potassium administration
- acidosis
How does acidosis cause hyperkalemia?
Acidosis causes a shift in potassium from the intracellular to the extracellular space, including the intravascular.
_____ _____ develops from the production of acids, such as lactic acid, when tissue perfusion is inadequate.
metabolic acidosis
How does sodium bicarb help resolve acidosis?
Acts as a buffer by combining with hydrogen ions to produce CO2 and water
In general, isotonic crystalloid should be given in a __ml/kg bolus over __ to __ minutes, unless you suspect _____ shock
- 20 ml/kg over 5 to 20 minutes
- cardiogenic
In cardiogenic shock, fluid resuscitation consists of __ to __ ml/kg given over __ to __ minutes.
- 5 to 10 ml/kg
- 10 to 20 minutes
The expected urine output for infants and young children is about __ to __ ml/kg per hour
1.5 to 2
What do inotropes do?
Increase cardiac contractility and heart rate
Dopamine, epinephrine, and dobutamine are all what
Inotropes
What is a phosphodiesterase inhibitor?
Give one example
- Decreases SVR
- Improves coronary artery blood flow
- Improves contractility
- ex. Milrinone
Give two examples of a vasodilator
- Nitroglycerin
- Nitroprusside
Blood and blood products are generally not used for volume expansion in children with shock unless shock is due to what
Hemorrhage
For children that have been poisoned, such as have ingested calcium channel blockers, give fluid resuscitation of __-__ ml/kg over __-__ minutes
- 5-10 ml/kg
- Over 10-20 minutes
A pediatric patient in DKA should receive fluid resuscitation at the rate of __-__ ml/kg over what amount of time?
- 10 - 20
- over a matter of time governed by local protocol, if used give over at least 1 - 2 hours
Hypoglycemia in preterm neonates and term neonates is defined as a blood sugar below what
45
For the purposes of the PALS Provider course, shock is categorized into 4 types, what are they?
- hypovolemic
- distributive
- cardiogenic
- obstructive
Clinically significant dehydration in children is generally associated with at least __% volume depletion, corresponding with a fluid deficit of __ ml/kg or greater
- 5 %
- 50 mL/kg
Shock may be observed in children with fluid deficits of __ to __ ml/kg, but is more consistently observed with deficits of __ ml/kg or greater
- 50 to 100
- 100
Failure to improve after 3 boluses of 20 ml/kg may indicate what?
(4)
- The extent of fluid losses may be underestimated
- They type of fluid being used may need to be altered (eg, colloid or blood)
- There are ongoing fluid losses (eg, occult bleeding )
- Your initial assumption about the etiology of the shock may be incorrect
In children, the dividing line between mild and compensated vs moderate to severe hypotensive hemorrhagic shock is thought to correlate with an acute loss of about __% of blood volume.
30
The estimated total blood volume of a child is about __ to __ ml/kg.
75 - 80
For fluid resuscitation in hemorrhagic shock, give about __ ml of isotonic crystalloid for every __ ml of blood lost
- 3
- 1
- known as the 3 to 1 rule
Name three types of distributive shock
- Septic
- Anaphylactic
- Neurogenic
What is the difference between primary and secondary bradycardia?
Primary bradycardia:
- Primary bradycardia is the result of congenital abnormalities or acquired injury to the heart’s pacemaker cells or conduction system.*
- Some of the causes of primary bradycardia are myocarditis, surgical injury, cardiomyopathy, and congenital abnormalities of the heart or the heart’s conduction system.
Secondary bradycardia:
- Secondary bradycardia is caused by non-cardiac problems*.
- These problems result in abnormal functioning of the heart. Secondary bradycardia is typically the type of bradycardia seen in infants and children.
What are some causes of secondary bradycardia?
(5)
- hypoxia
- acidosis
- hypotension
- hypothermia
- drug effects
What is the dose per IV/IO for epinephrine?
What is the dose per ET tube?
- 0.01 mg/kg per IV/IO
- ET tube 0.1 mg/kg
What is the dose for atropine via the IV/IO route?
- 0.02 mg/kg; minimum 0.1 mg, maximum 0.5 mg
- may repeat dose once, five minutes after the first
What is the dose for atropine via the ET tube route?
0.04 to 0.06 mg/kg
For infants in SVT in need of a vagal maneuver, what is the preferred method?
- ice bag to the face
- older children who can cooperate may blow through a straw
What is the drug of choice for the treatment of SVT?
What is the dose?
- Adenosine
- 0.1 mg/kg, max initial dose 6 mg as rapid IV bolus
If the first dose of adenosine is effective, the rhythm will convert within __ to __ seconds. If not, what is the second dose?
- 15 to 30 seconds
- 0.2 mg/kg, max 2nd dose is 12 mg
What is a common cause of adenosine failure?
Not pushed fast enough or not with an adequate fluid bolus
ABG values
What is the normal range for pH?
7.35 - 7.45
ABG values
What is the normal range for PO2?
80 - 100 mmHg
ABG values
What is the normal range for PCO2?
35 - 45 mmHg
ABG values
What is the normal range for HCO3 (bicarb)?
22 - 28 mEq/L
What are the 4 ABG lab values?
- O2
- PCO2
- pH
- Bicarb HCO3
What is a way to relieve gastric inflation post ROSC?
insert a G tube
What is the DOPE mnemonic and what is used for?
- Displacement of the tube; may be out of the trachea and into the right or left bronchus
- Obstruction of the tube
- Pneumothorax; stated as above, look for midline trachea
- Equipment failure
- Sudden deterioration of the intubated patient
Give 3 reasons during post ROSC that you should use a neuromuscular block
- High peak or mean airway pressure caused by high airway resistance or reduced lung compliance
- Patient / ventilator asynchrony
- Difficult airway
When using a neuromuscular block, what are 3 things you should keep in mind that the block can mask or doesn’t do?
- The block can mask seizures
- Does not provide pain relief
- Does not provide sedation
When using a neuromuscular block on a child with an ET tube, what are 5 things you should look for signs of?
Why?
- Look for signs of stress, tachycardia, hypertension, pupil dilation, and tearing.
- Neuromuscular blocks do not provide analgesia or sedation.
If a child has an elevated anion gap but a normal lactate, what should you look for?
Other causes of acidosis, such as toxins or uremia
What is the lab value used to monitor metabolic acidosis?
lactic acid, anion gap
What does SVR stand for?
Systemic Vascular Resistance
pg 289
What are three drugs to consider after a child remains hypotensive after a fluid bolus administration?
- Epinephrine
- Dopamine
- Norepinephrine
What is the drip rate for a hypotensive child treated with epinephrine?
0.1 - 1 mcg/kg per minute
What is the drip rate for a hypotensive child treated with Dopamine?
10 - 20 mcg/kg per minute
What is the drip rate for a hypotensive child treated with Norepinephrine?
0.1 - 2 mcg/kg per minute
If a child is normotensive and remains poorly perfused after bolus administration, name 5 drugs you may consider.
Dobutamine
Dopamine
Low dose epinephrine
Milrinone
inamrinone
