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Pediatric Resident Curriculum for the PICU

SHOCK IN CHILDREN
 Pediatric Resident Curriculum for the PICU Definition
Circulatory system failure to supply
oxygen and nutrients to meet cellular
metabolic demands
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 Pediatric Resident Curriculum for the PICU Other Definitions

Blood Pressure
BP = CO x SVR
Cardiac Output
CO = SV X HR
Vascular Tone (SVR)
Regulated by several mechanisms
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 Pediatric Resident Curriculum for the PICU Oxygen Delivery
DO2 = CO x CaO2 x 10
Remember: CO depends on HR, preload,
afterload, and contractility
CaO2 = Hgb x 1.34 x SaO2 + (PaO2 x 0.003)

Remember: hemoglobin carries more than 99%

of oxygen in the blood under standard
conditions
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 Pediatric Resident Curriculum for the PICU Hemodynamics
Myocardial
Contractility

Stroke Volume Preload

Cardiac Output Afterload

Blood
Pressure Heart Rate
Systemic Vascular
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Resistance

Textbook of Pediatric Advanced Life Support, 1988

 Pediatric Resident Curriculum for the PICU Defending the blood pressure
Neural Sympathetic Humoral
Baroreceptors Adrenal medulla
Carotid Body Catecholamines
Aortic Arch
Hypothalamopituitary
Volume receptors response
Right Atrium
Adrenocorticotropic
Pulmonary vascular hormone
Chemoreceptors Vasopressin
Aortic and carotid
Renin-angiotensin-
Medullary
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aldosterone system
Cerebral ischemic
response

 Pediatric Resident Curriculum for the PICU Cardiovascular function

Cardiac Output
Clinical Assessment
peripheral perfusion, temperature, capillary
refill, urine output, mentation, acid-base status
CO = HR x SV
HR responds the quickest
SV is a function of three variables
preload, afterload, and myocardial contractility
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A noncompliant heart cannot increase SV

 Pediatric Resident Curriculum for the PICU Stroke Volume
Preload (LVEDV)
Reflects patients volume status
CVP or PCWP
Starling curve
Afterload
The resistance to ventricular ejection
Two variables:
vascular tone and transmural pressure
Myocardial Contractility (squeeze)
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Many factors including coronary perfusion, baseline

myocardial function, use of cardiotonic medications

 Pediatric Resident Curriculum for the PICU Classification of Shock
COMPENSATED
blood flow is normal or increased and may be
maldistributed; vital organ function is maintained

UNCOMPENSATED
microvascular perfusion is compromised; significant
reductions in effective circulating volume

IRREVERSIBLE
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inadequate perfusion of vital organs; irreparable

damage; death cannot be prevented

 Pediatric Resident Curriculum for the PICU Other Classifications
Hypovolemic or Hemorrhagic
Cardiogenic
Obstructive
Distributive
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 Pediatric Resident Curriculum for the PICU Cardiovascular Changes in Shock

Type Preload Afterload Contractility

Cardiogenic
Hypovolemic No change
Distributive
Septic
early
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late

 Pediatric Resident Curriculum for the PICU Evaluation
Regardless of the cause: ABCs
First assess airway patency, ventilation, then
circulatory system
Respiratory Performance
Respiratory rate and pattern, work of breathing,
oxygenation (color), level of alertness
Circulation
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Heart rate, BP, perfusion, and pulses, liver size

CVP monitoring may be helpful

 Pediatric Resident Curriculum for the PICU Evaluation
Early Signs of Shock
sinus tachycardia
delayed capillary refill
fussy, irritable
Late Signs of Shock
bradycardia
altered mental status (lethargy, coma)
hypotonia, decreased DTRs
Cheyne-Stokes breathing
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hypotension is a very late sign

Lower limit of SBP = 70 + (2 x age in years)

 Pediatric Resident Curriculum for the PICU Cardiovascular
Assessment
Heart Rate Skin Perfusion
Too high: 180 bpm for Capillary refill time
infants, 160 bpm for Temperature
children >1year old Color
Blood Pressure Mottling
Lower limit of SBP = CNS Perfusion
70 + (2 x age in years) Recognition of parents
Reaction to pain
Peripheral Pulses Muscle tone

Present/Absent Pupil size
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Strength (diminished, Renal Perfusion

normal, bounding) UOP >1cc/kg/hr

 Pediatric Resident Curriculum for the PICU Treatment
Airway management
Always provide supplemental oxygen
Endotracheal intubation and controlled ventilation
is suggested if respiratory failure or airway
compromise is likely
elective is safer and less difficult
decrease negative intrathoracic pressure
improved oxygenation and O2 delivery and
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decreased O2 consumption
can hyperventilate if necessary

 Pediatric Resident Curriculum for the PICU Treatment
Circulation
Based on presumed etiology
Rapid restoration of intravascular volume
PIV-if unstable you have 60-90 seconds
I.O. if less than 4-6 years old
Central venous catheter
Use isotonic fluid: NS, LR, or 5% albumin
PRBCs to replace blood loss or if still unstable
after 60cc/kg of crystalloid
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anemia is poorly tolerated in the stressed,

hypoxic, hemodynamically unstable patient

 Pediatric Resident Curriculum for the PICU
Vasoactive/Cardiotonic
Agents
Dopamine
1-5 mcg/kg/min: dopaminergic
5-15 mcg/kg/min: more beta-1
10-20 mcg/kg/min: more alpha-1
may be useful in distributive shock

Dobutamine
2.5-15 mcg/kg/min: mostly beta-1, some beta-2
may be useful in cardiogenic shock
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Epinephrine
0.05-0.1 mcg/kg/min: mostly beta-1, some beta-2
> 0.1 to 0.2 mcg/kg/min: alpha-1

 Pediatric Resident Curriculum for the PICU
Vasoactive/Cardiotonic
Agents
Norepinephrine
0.05-0.2mcg/kg/min: only alpha and beta-1
Use up to 1mcg/kg/min

Milrinone
50mcg/kg load then 0.375-0.75mcg/kg/min:
phosphodiesterase inhibitor; results in increased inotropy
and peripheral vasodilation (greater effect on pulmonary
vasculature)
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Phenylephrine
0.1-0.5mcg/kg/min: pure alpha

 Pediatric Resident Curriculum for the PICU Hypovolemic
# 1 cause of death in children worldwide
Causes
Water Loss (diarrhea, vomiting with poor PO
intake, diabetes, major burns)
Blood Loss (obvious trauma; occult bleeding
from pelvic fractures, blunt abdominal
trauma, shaken baby)
Low preload leads to decreased SV and decreased
CO.
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Compensation occurs with increased HR and SVR

 Pediatric Resident Curriculum for the PICU Hypovolemic Shock
Mainstay of therapy is fluid
Goals
Restore intravascular volume
Correct metabolic acidosis
Treat the cause
Degree of dehydration often underestimated
Reassess perfusion, urine output, vital signs...
Isotonic crystalloid is always a good choice
20 to 50 cc/kg rapidly if cardiac function is normal
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NS can cause a hyperchloremic acidosis

 Pediatric Resident Curriculum for the PICU Treatment
Solution Na+ Cl- K+ Ca++ Mg++ Buffer
NS 154 154 0 0 0 None
LR 130 109 4 3 0 Lactate
Plasmalyte 140 98 5 0 3 Acetate
& Gluconate

Inotropic and vasoactive drugs are not a substitute for fluid,

however...
Can have various combinations of hypovolemic and septic and
cardiogenic shock
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May need to treat poor vascular tone and/or poor cardiac

function

 Pediatric Resident Curriculum for the PICU Hemorrhagic Shock
Treatment is PRBCs or whole blood
Treat the cause if able (stop the bleeding)
Transfuse if significant blood loss is known or
if patient unstable after 60cc/kg crystalloid
In an emergency can give group O PRBCs
before cross matching is complete or type
specific non-cross-matched blood products
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 Pediatric Resident Curriculum for the PICU Cardiogenic
Low CO and high systemic vascular resistance
Result of primary cardiac dysfunction:
A compensatory increase in SVR occurs to
maintain vital organ function
Subsequent increase in LV afterload, LV

work, and cardiac oxygen consumption

CO decreases and ultimately results in
volume retention, pulmonary edema, and
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RV failure

 Pediatric Resident Curriculum for the PICU
Cardiogenic Shock
Etiologies
Congenital heart Late septic shock
disease Infiltrative diseases
Arrhythmias mucopolysaccharidoses
Ischemic heart glycogen storage
disease diseases
Myocarditis Thyrotoxicosis
Myocardial injury Pheochromocytoma
Acute and chronic
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drug toxicity

 Pediatric Resident Curriculum for the PICU Cardiogenic Shock
Initial clinical presentation can be identical to
hypovolemic shock
Initial therapy is a fluid challenge
If no improvement or if worsens after giving
volume, suspect cardiogenic shock
Usually need invasive monitoring, further
evaluation, pharmacologic therapy
Balancing fluid therapy and inotropic support can
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be very difficult.
Call an intensivist and/or a cardiologist

 Pediatric Resident Curriculum for the PICU Obstructive Shock
Low CO secondary to a physical obstruction to flow
Compensatory increased SVR
Causes:
Pericardial tamponade
Tension pneumothorax
Critical coarctation of the aorta
Aortic stenosis
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Hypoplastic left heart syndrome

 Pediatric Resident Curriculum for the PICU Obstructive Shock
Initial clinical presentation can be identical to
hypovolemic shock
Initial therapy is a fluid challenge
Treat the cause
pericardial drain, chest tube, surgical
intervention
if the patient is a neonate with a ductal
dependent lesion then give PGE
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Further evaluation, invasive monitoring,

pharmacologic therapy, appropriate consults

 Pediatric Resident Curriculum for the PICU Distributive Shock
High CO and low SVR (opposite of hypovolemic,
cardiogenic, and obstructive)
Maldistribution of blood flow causing
inadequate tissue perfusion
Due to release of endotoxin, vasoactive
substances, complement cascade activation,
and microcirculation thrombosis
Early septic shock is the most common form
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 Pediatric Resident Curriculum for the PICU Distributive Shock
Goal is to maintain intravascular volume and
minimize increases in interstitial fluid (the
primary problem is a decrease in SVR)
Use crystalloid initially
Additional fluid therapy should be based on lab
studies
Can give up to 40cc/kg without monitoring CVP
Vasoactive/Cardiotonic agents often necessary
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Treat the cause (i.e.. antimicrobial therapy)

 Pediatric Resident Curriculum for the PICU
Distributive Shock
Etiologies
Anaphylaxis
Anaphylactoid reactions
Spinal cord injury/spinal shock
Head injury
Early sepsis
Drug intoxication
Barbiturates, Phenothiazines,
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Antihypertensives

 Pediatric Resident Curriculum for the PICU
Metabolic Issues
Acid-Base
Metabolic acidosis develops secondary to tissue
hypoperfusion
Profound acidosis depresses myocardial
contractility and impairs the effectiveness of
catecholamines
Tx: fluid administration and controlled ventilation
Buffer administration
Sodium Bicarbonate 1-2meq/kg or can calculate a 1/2
correction = 0.3 x weight (kg) x base deficit
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hyperosmolarity, hypocalcemia, hypernatremia, left-

ward shift of the oxyhemoglobin dissociation curve

 Pediatric Resident Curriculum for the PICU
Metabolic Issues
Electrolytes
Electrolytes
Calcium is important for cardiac function and
for the pressor effect of catecholamines
Hypoglycemia can lead to CNS damage and is
needed for proper cardiovascular function
Check the BUN and creatinine to evaluate renal
function
Hyperkalemia can occur from renal dysfunction
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and/or acidosis

 Pediatric Resident Curriculum for the PICU
Metabolic Issues
Special Topics
Congenital adrenal hyperplasia
Infant presents in shock, usually in the second week
of life, typically a boy, with metabolic acidosis,
hyponatremia, hypoglycemia, and hyperkalemia

Hyperammonemia
mild elevations are common with shock
levels > 1000 are consistent with inborn errors of
metabolism
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consider Reye Syndrome, toxins, hepatic failure

 Pediatric Resident Curriculum for the PICU Other Studies
Look for etiology of shock
Evaluate hemoglobin, hematocrit, and platelet
count
Should be followed as these values may drop after
fluid resuscitation
Shock from any etiology can lead to DIC and end
organ damage
CBC, PT, INR, PTT, Fibrinogen, Factor V, Factor
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VIII, D-dimer, and/or FDPs

Check LFTs, follow CNS and pulmonary status

 Pediatric Resident Curriculum for the PICU Other Studies II

Think about inborn errors of metabolism

Lactate and pyruvate
Ammonium, LFTs
Plasma amino acids, urine organic acids
Urinalysis with reducing substances
Urine tox screen
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 Pediatric Resident Curriculum for the PICU Conclusion
Goal of therapy is identification, evaluation, and
treatment of shock in its earliest stage
Initial priorities are for the ABCs
Fluid resuscitation begins with 20cc/kg of
crystalloid or 10cc/kg of colloid
Subsequent treatment depends on the etiology of
shock and the patients hemodynamic condition
Successful resuscitation depends on early and
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judicious intervention