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PALS > Shock > Flashcards

Shock Flashcards

1
Q

Shock is inadequate _____ that results from _______ to deliver sufficient ______ to sustain vital organ function.

A

Tissue perfusion; the failure of the CVS; oxygen and nutrients.

Also called hypoperfusion or circulatory failure

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2
Q

Conductance vessels

A

Arteries

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3
Q

Resistance vessels

A

Arterioles

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4
Q

Exhcnage vessels

A

Capillaries

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5
Q

Capacitance/storage vessels

A

Veins

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6
Q

Pediatric vs adult patient: Capable of more effective vasoconstriction? What is the consequence of this?

A

Pediatric; Greater ability to maintain normal blood pressure for a longer time in the presence of shock

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7
Q

Pressure exerted against the walls of the large arteries at the peak of ventricular contraction

A

Systolic blood pressure

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8
Q

Pressure exerted against the walls of large arteries during ventricular relaxation

A

Diastolic blood pressure

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9
Q

BP = ___ x ___?

A

BP = CO x TPR

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10
Q

Important formula for resistance?

A

Poiseuille’s Law
R = 8nl/(pi)r^4
where n = viscosity, l = length of blood vessel, r = radius of blood vessel

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11
Q

Pulse pressure reflects?

A

Stroke volume and aortic compliance (SV/AC) `

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12
Q

Narrowed pulse pressure reflects?

A

Increased TPR, EARLY sign of impending shock

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13
Q

Widened pulse pressure reflects?

A

Decreased TPR, seen in EARLY septic shock/warm shock/hyperdynamic shock

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14
Q

Early indicators of decreased tissue perfusion

A

Mottling, cool extremities

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15
Q

Late sign of cardiovascular compromise in a child

A

Hypotension

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16
Q

What happens to peripheral pulses when cardiac output is decreased?

A

Also decreased

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17
Q

CO = ___ x ___

A

CO = HR x SV

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18
Q

Primary method of increasing cardiac output in children?

A

Increase HR

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19
Q

Why are children dependent on an adequate HR to maintain cardiac output? *Also the rationale behind faster HR in infants –> slower HR as the child grows older

A

Due to the immaturity of the sympathetic innervation to the ventricles, the heart is unable to increase CO by increasing SV (EDV - ESV). The myocardia are less compliant and less able to generate tension during contraction, limiting SV. As these mature, children become more able to maintain cardiac output by increasing SV.

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20
Q

Circulating blood volume in:
Infants
Children
Adolescents and adults

A

Infants: 75-80 mL/kg
Children: 70-75 mL/kg
Adolescents and adults: 65-70 mL/kg

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21
Q

Physiologic reserves
Glycogen stores
Glucose requirements
Cardiovascular reserve

A

Glycogen stores: Less
Glucose requirements: More
Cardiovascular reserve: Greater CIRCULATING blood volume than adults, but less TOTAL blood volume; strong but limited reserves. Decompensate QUICKLY.

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22
Q

Compensated shock

A

Early shock, inadequate tissue perfusion without hypotension

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23
Q

Body’s sensors and compensatory mechanisms in shock?

A

Carotid sinus: Baroreceptor; decreased vagal firing rate when BP drops –> increased sympathetic outflow from the CNS –> increased HR, SV, TPR
Medulla, carotid bodies, aortic arch: Chemoreceptors; stimulated mostly by hypoxia, but also by hypercarbia and low pH –> increased RR to blow off CO2

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24
Q

Physical findings in compensated shock?

A 
Narrow pulse pressure, normal SBP
Normal to mild increase in HR
Mild increase in RR
Mild decrease in urine output
Mental status changes such as restlessness, irritability, confusion
Pale mucous membranes
25
Q

Hypotensive shock

A

Occurs when compensatory mechanisms begin to fail

26
Q

Physical findings in hypotensive shock?

A

Fall in SBP, DBP; weak central pulses, thready peripheral pulses
Moderate tachycardia, possible dysrhythmias
Moderate increase in RR, possible respiratory fatigue or failure
Marked decrease in urine output
Agitation, lethargy
Pale or cyanotic mucous membranes

27
Q

What does pulse quality reflect?

A

Adequacy of peripheral perfusion

28
Q

What are the four types of shock?

A

Hypovolemic
Distributive
Cardiogenic
Ostructive

29
Q

Sudden decrease in the circulating blood volume relative to the capacity of the vascular space

Ex. hemorrhage, plasma loss, fluid and electrolyte loss, endocrine disease

A

Hypovolemic shock

30
Q

Distributive shock

A

Altered vascular tone –> peripheral vasodilation –> increases the size of the vascular space and alters the distribution of the available blood volume –> RELATIVE hypovolemia

Ex. septic shock, anaphylactic shock, neurogenic shock

31
Q

Cardiogenic shock

A

Impaired cardiac muscle function leads to decreased cardiac output and inadequate tissue oxygenation

Ex. conduction abnormalities, cardiomyopathy, congenital heart disease

32
Q

Obstructive

A

Obstruction to ventricular filling or the outflow of blood from the heart

Ex. tension pneumothorax, massive pulmonary embolus, cardiac tamponade

33
Q

A 5-year-old child presents with a 3-day history of vomiting and diarrhea. On physical exam, he has poor skin turgor, has cool extremities, and is irritable. What is/are the type/s of shock involved?

A

Hypovolemic shock due to fluid and electrolyte loss.

34
Q

A 12-year-old child was involved in a vehicular crash when his bike collided with a speeding car. He was not wearing a helmet, and his head hit the sidewalk when he was thrown off his bike. On PE, he is unresponsive to any kind of stimulus, hypotensive, bradycardic, with irregular respirations. Breath sounds are decreased in the left lung field, no neck vein distension. He has weak peripheral pulses and cool extremities. What type/s of shock is/are involved?

A

Distributive: Neurogenic, involvement of cervical spine will present with hypotension and bradycardia
Possible hypovolemic: Decreased breath sounds in the left lung field may indicate a hemothorax, and there may also be other sources of internal hemorrhage (abdominal, pelvic fracture)

35
Q

Four clinical findings to assess dehydration

A

Abnormal general appearance
Capillary refill >2s
Dry mucous membranes
Absent tears

36
Q

Priorities in emergent care of a pediatric patient in hypovolemic shock?

A

Control fluid loss

Restore vascular volume

37
Q

How do you perform fluid resuscitation in children?

A

20 cc/kg of isotonic crystalloid solution (ex. pNSS or pLR)
Assess response after EACH BOLUS: increased work of breathing, development of crackles
Generally, 3 mL fluid: 1 mL blood lost

38
Q

What should be the next steps to consider if the patient does not respond to the initial fluid resuscitation?

A 
Blood transfusion (if hemorrhagic etiology)
Use of vasopressors --> when shock remains refractory after 60-80 cc/kg bolus
39
Q

How is hypoglycemia managed?

A

Newborn: 5-10 cc/kg D10W
Infants and children: 2-4 cc/kg D25W
Adolescents: 1-2 cc D50W

*In Harriet Lane though, it’s just 2 cc/kg D10 W for newborns

40
Q

What is the most common type of distributive shock in children?

A

Septic shock

41
Q

What are the two stages of septic shock?

A

Early/warm shock/hyperdynamic phase: Where endotoxins prevent catecholamine-induced vasoconstriction –> peripheral vasodilation –> increased cardiac output to maintain adequate oxygen delivery

Late/cold shock/hypodynamic phase: Inflammatory mediators cause cardiac output to fall –> compensatory increase TPR –> cool extremities (cold shock)

42
Q

Goals in emergent management of a patient in septic shock?

A 
Restore hemodynamic instability
Identify and control infectious organism
Limit inflammatory response
Support CVS
Enhance tissue perfusion
Ensure nutritional therapy
43
Q

Initial therapeutic endpoints in resuscitation of septic shock

A 
Capillary refill <2 s
Normal BP for age
Normal pulses
Warm extremities
UO > 1 cc/kg/hr
Normal mental status
44
Q

Other therapeutic considerations in septic shock:

A

Inotropic support
Mechanical ventilation
Correction of glucose, iCa, other electrolyte abnormalities
Broad-spectrum antibiotic

45
Q

What pressor is given for warm shock with low BP?

A

Norepinephrine: 0.1 - 2 mcg/kg/min

46
Q

What pressor is given for cold shock with normal BP?

A

Dopamine: 2-20 mcg/kg/min (5-20 in Harriet Lane); this is medium dose, acts more on beta receptors, increases cardiac contractility with little effect on vascular resistance

47
Q

What is given for cold shock with low BP?

A

Epinephrine: 0.1 mcg/kg/min

48
Q

What is the mainstay of treatment in anaphylaxis?

A

Epinephrine 0.01 mcg/kg of 1:1000 (1 mg/mL), IM at anterolateral thigh
Then support with fluids, salbutamol for bronchospasm, methyprednisolone, diphenhydramine

49
Q

Goals in the emergent management of cardiogenic shock?

A 
Reduce myocardial oxygen demand
Improve preload
Reduce afterload
Improve contractility
Correct dysrhythmias
50
Q

How do you perform fluid resuscitation in a patient with cardiogenic shock?

A

Small fluid bolus (5-10 cc/kg) given over 10-20 minutes

51
Q

When are vasopressors given in those with cardiogenic shock?

A

Significant hypotension
Unresponsive to fluid resuscitation
Volume overloaded

52
Q

Intropes with vasoconstrictor effect

A

Epinephrine, norepinephrine, dopamine (at high doses)

53
Q

Inotropes with vasodilator effect

A

Dopamine (at low doses), isoprotenerol, dobutamine, amrinone, milrinone

54
Q

Possible causes of obstructive shock

A

Cardiac tamponade
Tension pneumothorax
CHD
Massive pulmonary embolism

55
Q

Site for needling?

A

2nd ICS, insert 14- or 16-G needle on top of the 3rd rib, remove needle once there is a popping sound or give, then leave catheter in place

56
Q

In babies with signs of decompensation due to CHD, what should you administer?

A

IV infusion of PGE1 (ex. alprostadil) to keep DA patent

57
Q

In cases where peripheral vascular access cannot be found, what is the next step?

A

Intraosseus route, in the ff locations:
Proximal tibia: 1-3 cm below and medial to the tibial tuberosity in the flat surface of the tibia
Distal tibia: 1-2 cm proximal to the medial malleolus in the midline
Distal femur: 2-3 cm above femoral condyles in the midline
Head of humerus: Two finger widths below coracoid process and acromion

58
Q

Remove IO access by?

A

24 hrs to prevent osteomyelitis

PALS (2 decks)

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