Paediatric Shock Flashcards
What is shock?
Lack of perfusion to the peripheries leading to a lack of adequate cellular metabolism, leading to the accumulation of cellular waste
What features are suggestive of septic shock?
- Localising symptoms
- Fulminant DIC with purpuric rash
- NOT FEVER
Are patients with septic shock febrile?
NO. Fever is not the defining feature of septic shock. May be cold, euthermic or febrile.
What causes cold septic shock?
- Cardiac dysfunction due to lactic academy from septic process
- Children cannot increase SV, only inc HR to inc CO
What is warm septic shock? Features?
Vasodilatory:
- fever
- bounding pulse
- wide pulse pressure
Young or older children more likely to present with warm septic shock?
The older the child, the more likely warm shock.
Mx septic shock?
Resuscitation Pod.
- ABCs
- Prompt ABx (within 30minutes of arrival).
- Fluid resuscitation
- Consider inotropes
- Fluid, inotrope resistant = ECMO
Components of C in primary survey of septic shock?
- 2x IV access attempts; prepare for IO / umbilical
- Bloods: B/C, BSL, VBG (for lactate)
Organisms to cover and ABx for neonates with septic shock?
Neonates (GBS, E coli, Listeria):
- empirical: benzylpenicillin, cefotaxime.
- If UTI: add gentamicin.
Older children: ABx and organisms in septic shock?
Older children (Staph, strep, meningicoccal ):
- flucloxacillin
- 3rd generation ceph (cefotaxime or ceftriaxone) for BBB access
Immunocompromised / neutropenic patients: ABx and organisms to cover in septic shock?
- Tazocin: cover pseudomonas
- Vancomycin (MRSA)
Approach to fluid resuscitation in paediatric septic shock?
20ml/kg NS - 40ml/kg (in older children), then stand at the bed to watch the HR, peripheral perfusion
• With rapid assessment of another bolus, continue to bolus them
• Start drawing up inotropes if starting 40ml/kg
Neonatal be careful: as sepsis can masqeurade cardiogenic shock (CHD)
Why do septic shock patients respond poorly to fluid resuscitation?
Fluids resuscitation - do not respond as well to this because they have leaky vessels
Why is warm septic shock v cold septic shock important to determine when giving inotropes?
- Warm shock, the problem is vasodilation: therefore give NA to vasoconstrict
- Cold shock: adrenaline to increase pump
Why do neonates often get started on dobutamine?
Shock is more commonly cariogenic and cold septic shock.
Can NA and adrenaline be given peripherally?
Yes but diluted. Tissue necrosis if given undiluted.
Post resuscitation care after septic shock?
- Monitor BSL
- Monitor BP and maintain
- VBG: monitor CO2, electrolytes, pH
- ABG is important to look at PO2 therefore take when intubated and lactate
Which CHD lesions generally present in shock?
The PDA dependent lesions:
- Critical AS
- Coarctation
- Transposition
How do neonates with cardiogenic shock preesent?
- Floppy
- Cold
- Mottled
- Poor feeding
(Looks similar to septic neonate).
+/-:
- Murmur
- Four limb BP
- Decreased femoral pulses
What are the causes of cardiogenic shock in older children?
- Myocarditis
- AMI
- Ongoing SVT
How long can umbilical artery / vein access be obtained?
Up to 4 days
Mx cardiogenic shock?
- AB
- C: access
- Cautious 10mL/kg NS
- PGE
- Still ABx as hard to differentiate
- Dobutamine in most
What is the biggest danger of PGE?
Apnoea. Must always prepare for:
- intubation
- transfer
Causes of hypovolaemic shock?
Fluid: - Gastro - DKA Blood: - Haemorrhage (trauma) - Bleeding from PUD or GIT lesion
Sites of occult blood loss?
- Chest
- Pelvis
- Abdo
- Long bones
- Head (in neonates)
Approach to hypovolemic shock?
AB (with O2) C: - Gain access - IVABx if ?sepsis - Bloods: +UEC and BSL (?DKA) -Fluid 20mL/kg: most resolve after first bolus. Keep bolus until out of shock and into dehydration (if correct DKA into normovolemia will get cerebral oedema)
Aim of fluid bolus in hypovolemic shock? Why?
Keep bolusing until out of shock and into dehydration (if correct DKA into normovolemia will get cerebral oedema)
What are the signs of cardiac tamponade?
Beck’s Triad:
- Distended neck veins
- Poor pulses
- Muffled heart sounds
Causes of obstructive shock?
Usually traumatic causes of:
- Tension pneumo
- Cardiac tamponade
- PE (if adolescent on OCP)
Mx of cardiac tamponade?
- ABCD
- Pericardial window
- If arrest, then emergency pericardiocentesis
- Echo to diagnose
What is distributive shock?
i. e. anaphylaxis:
- Respiratory or CV features PLUS
- Mucocutaneous or GI effects
