Pediatric Shock

Question 1

differences between adult and pediatrick shock

Answer 1

Pediatric vs Adult Shock

Children increase HR and SVR as main compensatory response to decreased cardiac output →unlike adults, kids cannot increase their contractility in order to modulate the cardiac output!! They have too little muscle mass.

Vasoconstriction mechanisms are excellent until process progresses untreated for long time→ therefore, hypotension is a late finding

Beware of early tachycardia

Question 2

formula to assess if the pediatric shock is compensated or uncompensated

Answer 2

Compensated and Decompensated shock

BP!: compensated = normal

BP, decompensated = hypotension

For kids, normal SBP= 70+ (2x age in years)

Kids have increased physiologic reserve, good compensatory mechanisms and will maintain BP until shortly before arrest.

You don’t have much time to act if they are hypotensive\

It’s easy to miss compensated shock– beware of tachycardia, act quickly to prevent progression to hypotension. Prompt fluid resuscitation saves lives.

Question 3

which two types of shock are most common in children

Answer 3

hypovolemic and distributive shock is most common.

Hypovolemic causes: blood loss, dehydration

Distributive: sepsis, anaphylaxis

Question 4

causes of hypovolemic shock

Answer 4

Causes: blood loss, dehydration (gastro, decreased intake, burns causing 3rd spacing)

Question 5

Signs and Symptoms: sunken eyes, no tears, dry mucous membranes, delayed cap refill, poor skin turgor, cool extremities, tachycardia, hypotension, effortless tachypnea (to compensate for metabolic acidosis)

these signs are indicative of ___ shock

Answer 5

hypovolemic shock

Question 6

management of hypovolemic shock:

Management: oxygen, IV access with normal saline (___/kg), OR ___ for burns, ____ for trauma/blood loss

If you can’t get IV, need ___ access (do not put in bone that was previously used, fractured bone, bone at risk for fracture)

Can tell IO is in by feeling a drop in resistance during insertion, needle stands firm without moving, bone marrow can be aspirated, flushes easily, and no soft tissue swelling with infusion

Complications of IO: subcutaneous infiltration, compartment syndrome, fracture, growth plate injury, infection, local hematoma, compartment syndrome from fluid extravasation

Answer 6

Management: oxygen, IV access with normal saline (20ml/kg), OR ringers for burns, pRBCs for trauma/blood loss

If you can’t get IV, need IO access (do not put in bone that was previously used, fractured bone, bone at risk for fracture)

Can tell IO is in by feeling a drop in resistance during insertion, needle stands firm without moving, bone marrow can be aspirated, flushes easily, and no soft tissue swelling with infusion

Complications of IO: subcutaneous infiltration, compartment syndrome, fracture, growth plate injury, infection, local hematoma, compartment syndrome from fluid extravasation

Question 7

definitions and causes of distributive shock

Answer 7

Definition: inappropriate vasodilation with a maldistribution of blood flow and increased vascular capacity (decreased preload and afterload)

Causes: neurogenic due to SC or head injury causing loss of sympathetic NS tone, medication/toxin (ex/ ingestion of vasodilating medication), sepsis, anaphylaxis

Question 8

SIRS criteria

Answer 8

Systemic Inflammatory Response Syndrome (SIRS): 2+ of

Abnormal temp

Abnormal HR

Abnormal RR or needing ventilation

Abnormal WBC

Question 9

warm shock vs cold shock in terms of septic distributive shock

Answer 9

warm shock: vasodilation and high cardiac output state

cold shock: vasoconstriction and low cardiac output state.

• children are often presenting with cold shock

Question 10

management of distrbutive shock

Answer 10

Management: oxygen, consider early intubation, 2 large bore IVs, give 20ml/kg normal saline or plasma-Lte bolus, empiric broad spectrum antibiotics within one hour

Reassess vitals and response to treatment

Max volumes?

• 60 mL/kg, then add vasoactive drugs for fluid-
• 20 mL/kg in “resource-limited settings” for infants refractory shock (type of drug depends on cold or warm shock), in setting with good critical care resources (eg. Canada) and children in shock from severe febrile illnesses including sepsis, malaria, and dengue; extreme caution with boluses (FEAST trial)

Question 11

how does management of anaphylaxis differ from management of normal distributive picture of shock?

Answer 11

1. stop antibiotics (could be causing the reacion)
2. epi
3. H1/H2 antagonist
4. corticosteroids to attempt to decrease risk of biphasic reaction

Dose: 0.01mg/kg IM, max: 0.5mg into thigh, may repeat in 5-15 min if needed

Oxygen

Nebulized epinephrine (stridor), nebulized salbutamol (wheeze), consider definitive airway management

For shock: IV access, NS/PLA bolus, IV epi

Consider second line therapy: H1 antagonist (diphenhydramine), H2 antagonist (ranitidine), corticosteroid (methylprednisolone)– attempt to decrease risk of biphasic reaction.

Question 12

Can COVID cause shock?

• Yes… it can cause vomiting and diarrhea, leading to ___ shock
• Yes… it can cause MIS-C (Multisystem Inflammatory Syndrome in Children), which is like Kawasaki disease + “vasoplegic” shock, ie. ___ shock
• Also COVID has been observed to cause myocarditis (potential for ___ shock) and thrombosis (potential for __ shock)

Answer 12

Can COVID cause shock?

• Yes… it can cause vomiting and diarrhea, leading to hypovolemic shock
• Yes… it can cause MIS-C (Multisystem Inflammatory Syndrome in Children), which is like Kawasaki disease + “vasoplegic” shock, ie. distributive shock
• Also COVID has been observed to cause myocarditis (potential for cardiogenic shock) and thrombosis (potential for obstructive shock)