DefinitionDefinition

Circulatory system failure to supplyCirculatory system failure to supplyoxygen and nutrientsoxygen and nutrients to meet cellular to meet cellular

metabolic demandsmetabolic demands. .

ShockShock Classification and causesClassification and causes::

HypovolemicHypovolemicDistributiveDistributiveCardiogenicCardiogenicObstructiveObstructivedissociativedissociative

HemodynamicsHemodynamics

MyocardialContractility

Stroke Volume Preload

Cardiac Output Afterload

Blood Pressure Heart Rate

Systemic Vascular Resistance

Textbook of Pediatric Advanced Life Support, 1988Textbook of Pediatric Advanced Life Support, 1988

Cardiovascular functionCardiovascular function

Cardiac OutputCardiac OutputCO = HR x SVCO = HR x SVHR responds the quickestHR responds the quickest

SV is a function of three variablesSV is a function of three variables: : preloadpreload , ,After loadAfter load , ,

myocardial contractilitymyocardial contractilityA noncompliant heart cannot increase SVA noncompliant heart cannot increase SV

Cardiovascular functionCardiovascular function

11--Cardiac OutputCardiac Output22--Clinical AssessmentClinical Assessment

peripheral perfusionperipheral perfusionTemperatureTemperaturecapillary refillcapillary refillurine outputurine outputMentationMentationacid-base statusacid-base status

Hypovolemic shockHypovolemic shock Definition:Definition: Decreased circulating blood volume.Decreased circulating blood volume.

Common causes:Common causes: HemorrhageHemorrhage DiarrheaDiarrhea Diabetes insipidusDiabetes insipidus Diabetes mellitusDiabetes mellitus BurnsBurns Adrenogenital syndromeAdrenogenital syndrome

Distributive shockDistributive shock DefinitionDefinition

Vasodilation and decreased preloadVasodilation and decreased preload

Common causesCommon causes::SepsisSepsisAnaphylaxisAnaphylaxisSpinal injurySpinal injuryDrug intoxicationDrug intoxication

Cardiogenic shockCardiogenic shock Decreased myocardial contractilityDecreased myocardial contractility

Common causes:Common causes: Congenital heart diseaseCongenital heart disease Severe heart failureSevere heart failure ArrhythmiaArrhythmia hypoxic ischemic injurieshypoxic ischemic injuries CardiomyopathyCardiomyopathy MyocarditisMyocarditis Drug intoxicationDrug intoxication kawasakikawasaki

Obstructive shockObstructive shockDefinitionDefinitionMechanicalMechanical obstruction to ventricular obstruction to ventricular

outflow.outflow.Common causes:Common causes: Cardaic tamponadeCardaic tamponade Massive pulmonary embolusMassive pulmonary embolus Tension pneumothoraxTension pneumothorax Cardiac tumorCardiac tumor

Dissociative shockDissociative shockDefinitionDefinition Oxygen not released from hemoglobin.Oxygen not released from hemoglobin.

Common causesCommon causes1.1. Carbon monoxide poisoningCarbon monoxide poisoning2.2. methemoglobinemiamethemoglobinemia

Organ directed Organ directed therapeuticstherapeutics

Cardiovascular supportCardiovascular support Fluid resuscitationFluid resuscitation Cardiotonic and vasodilatorCardiotonic and vasodilator therapy therapy RespiratoryRespiratory support support RenalRenal salvage salvage

Cardiovascular Changes in Cardiovascular Changes in ShockShock

Type Preload Type Preload Afterload Afterload ContractilityContractility

Cardiogenic

Hypovolemic No change

Distributive

Septicearly

late

EvaluationEvaluation Regardless of the cause: ABCRegardless of the cause: ABC

First assess airway patencyFirst assess airway patency ventilationventilation

then circulatory systemthen circulatory system

EvaluationEvaluation Respiratory PerformanceRespiratory Performance

Respiratory rate and patternRespiratory rate and pattern work of breathing work of breathing oxygenation (color)oxygenation (color) level of alertnesslevel of alertness

CirculationCirculation Heart rate, BP, perfusion, and pulses, liver Heart rate, BP, perfusion, and pulses, liver

sizesize CVP monitoring may be helpfulCVP monitoring may be helpful

EvaluationEvaluation Early Signs of ShockEarly Signs of Shock

sinus tachycardia.sinus tachycardia.

delayed capillary refill.delayed capillary refill.

fussy, irritable.fussy, irritable.

Late Signs of ShockLate Signs of Shock

EvaluationEvaluation Late Signs of ShockLate Signs of Shock

bradycardiabradycardia altered mental status (lethargy, coma)altered mental status (lethargy, coma) hypotonia, decreased DTR’shypotonia, decreased DTR’s Cheyne-Stokes breathingCheyne-Stokes breathing hypotension is a very late signhypotension is a very late sign

Cardiovascular Assessment Cardiovascular Assessment (con)(con)

CNS Perfusion

Recognition of parents Reaction to pain Muscle tone Pupil size

Renal Perfusion UOP >1cc/kg/hr

Cardiovascular Assessment Cardiovascular Assessment (con)(con)

Skin Perfusion

Capillary refill time Temperature Color Mottling

Therapy for shockTherapy for shock The key therapy is the recognition of The key therapy is the recognition of

shock in its early state.shock in its early state. Treating the signs and symptoms.Treating the signs and symptoms. Minimize cadiopulmonary work.Minimize cadiopulmonary work. Ensuring cardiac output blood pressure Ensuring cardiac output blood pressure

and gas exchangeand gas exchange

Hypovolemic ShockHypovolemic Shock Mainstay of therapy is fluidMainstay of therapy is fluid . .

Goals:Goals:

1.1. Restore intravascular volumeRestore intravascular volume2.2. Correct metabolic acidosisCorrect metabolic acidosis3.3. Treat the causeTreat the cause

Hypovolemic Shock Hypovolemic Shock (treatment)(treatment)

Degree of dehydration often underestimatedDegree of dehydration often underestimated Reassess perfusion, urine output, vital signs...Reassess perfusion, urine output, vital signs...

Isotonic crystalloid is always a good choiceIsotonic crystalloid is always a good choice 20 to 50 cc/kg rapidly if cardiac function is 20 to 50 cc/kg rapidly if cardiac function is

normalnormal NS can cause a hyperchloremic acidosisNS can cause a hyperchloremic acidosis

Other StudiesOther Studies

Look for etiology of shock.Look for etiology of shock.

Evaluate hemoglobin, hematocrit, and platelet count.Evaluate hemoglobin, hematocrit, and platelet count.

Shock from any etiology can lead to DIC and end organ Shock from any etiology can lead to DIC and end organ damagedamage

Other StudiesOther Studies CBC, PT, INR, PTT, Fibrinogen, Factor V, CBC, PT, INR, PTT, Fibrinogen, Factor V,

Factor VIIIFactor VIII

Check LFT’s, follow CNS and pulmonary Check LFT’s, follow CNS and pulmonary statusstatus

ConclusionConclusion

Goal of therapy is;Goal of therapy is; identificationidentification evaluationevaluation and treatment of shock in its earliest stageand treatment of shock in its earliest stage

Successful resuscitation depends on early and judicious Successful resuscitation depends on early and judicious interventionintervention

Initial priorities are for the ABC’sInitial priorities are for the ABC’s

ConclusionConclusion Fluid resuscitation begins with 20cc/kg of Fluid resuscitation begins with 20cc/kg of

crystalloid or 10cc/kg of colloidcrystalloid or 10cc/kg of colloid

Subsequent treatment depends on the Subsequent treatment depends on the etiology of shock and the patient’s etiology of shock and the patient’s homodynamic conditionhomodynamic condition

Related infection and shockRelated infection and shock InfectionInfection BacteremiaBacteremia Systemic inflammatory response syndrome : Systemic inflammatory response syndrome : (2 or>2 of following)(2 or>2 of following)(T>38(T>38 HR>90HR>90RR>20RR>20WBC>12000 or<4000)WBC>12000 or<4000)

Related infection and shockRelated infection and shock Sepsis:Sepsis: Systemic response to infectionSystemic response to infection

Sever sepsis:Sever sepsis: sepsis + organ dysfunctionsepsis + organ dysfunction(hypo perfusion, lactic acidosis, oliguria,or an (hypo perfusion, lactic acidosis, oliguria,or an

acute alter mental status)acute alter mental status)

Related infection and shockRelated infection and shock Septic shock:Septic shock: sepsis +hypotention despid adequate fluidsepsis +hypotention despid adequate fluid

Hypotention:Hypotention: systolic<9 or >4reductionsystolic<9 or >4reduction Multiple organ dysfuntionMultiple organ dysfuntion

BurnsBurns Disruption 3 key function of skinDisruption 3 key function of skin

1.1. Regulation of heat lossRegulation of heat loss2.2. presevation of body fluidpresevation of body fluid3.3. Barrier of the infectionBarrier of the infection

PatophisiologyPatophisiology Release inflammatory and vasoactive Release inflammatory and vasoactive

mediatorsmediators capillary permeability increasecapillary permeability increase Decrease plasma volume and cardiac Decrease plasma volume and cardiac

outputoutput Shock is common if borne > 10% -12%Shock is common if borne > 10% -12%

classificationclassification1.1. Depth of injuryDepth of injury2.2. Percent of body surface area involvedPercent of body surface area involved3.3. Location of the burnLocation of the burn4.4. Association with other injuriesAssociation with other injuries

Clinical manifestationClinical manifestation1-First – degree:1-First – degree: Red, painful dray Red, painful dray Superficial and limited to epidermis.Superficial and limited to epidermis. Heal in 3-6 daysHeal in 3-6 days

Clinical manifestationClinical manifestation2-Second degree:2-Second degree: Partial-thicking Partial-thicking 1-1-superficialsuperficial ( ( red,painful,red,painful,blisterblister) heal in ) heal in 10-10-

2121 days days2-deep dermal2-deep dermal( ( pale ,painful, yellowpale ,painful, yellow)) heal in 3 heal in 3

weeks , scarringweeks , scarring

Clinical manifestationClinical manifestation3-Third –degree:3-Third –degree: Full thickness ,require grafts if >1 cmFull thickness ,require grafts if >1 cm Avascular and coagulation necrosisAvascular and coagulation necrosis

4- fourth – degree:4- fourth – degree: Involve underling facia, muscle or boneInvolve underling facia, muscle or bone

Clinical manifestationClinical manifestation Sever burn:Sever burn: >15%Body surface>15%Body surface involves face or prineum involves face or prineum 2 and 3 –degree burns hands or feet 2 and 3 –degree burns hands or feet

circumfrential burn of extermity circumfrential burn of extermity inhalation injuryinhalation injury

Percent of body surface area Percent of body surface area involvedinvolved

Each upper extremity 9%Each upper extremity 9% each lower extremity 18% each lower extremity 18% Posterior trunk 18%Posterior trunk 18% Anterior trunh 18%Anterior trunh 18% Head 9% and prinium1%Head 9% and prinium1%Location is important :Location is important : Face, eyes, ears, feet, prinium, hand ,full Face, eyes, ears, feet, prinium, hand ,full

thicknessthickness

treatmenttreatment decision is based on :decision is based on : Extent of burnExtent of burn(% burn)(% burn) , body surface , body surface (location),(location),

type type of burn, of burn, associated injureassociated injure, , medical complication ,availability medical complication ,availability ambulatory managementambulatory management

Stop the burning processStop the burning process Fluid and electrolyte support Fluid and electrolyte support

((systemic copillary leaksystemic copillary leak))

treatmenttreatment

Significant burn , Second 24 hr dextrose Significant burn , Second 24 hr dextrose in0.25 normal in0.25 normal bolus 20cc/kg lactated Ringerbolus 20cc/kg lactated Ringer

Total fluid is 2-4cc/kg/percent burn/24 hrTotal fluid is 2-4cc/kg/percent burn/24 hr ((Half in first 8 hrHalf in first 8 hr) that equal 1cc/kg/hr of urine) that equal 1cc/kg/hr of urinesalinesaline Colloid therapy is needed if burn >30% bs Colloid therapy is needed if burn >30% bs

and provided after 24 hr with crystalloidand provided after 24 hr with crystalloid

treatmenttreatment Nutritional support:Nutritional support: ( burn produce hypermetabolic response ( burn produce hypermetabolic response

that sedation and analgesic can decrease)that sedation and analgesic can decrease)

In critical burn parenteral nutrition In critical burn parenteral nutrition Enteral feeding résumé on 2-3 daysEnteral feeding résumé on 2-3 days

treatmenttreatment Wound care:Wound care: Relief any pressure on cerculationRelief any pressure on cerculation Covered with sulfadiazin Covered with sulfadiazin GraftGraft Tetanus toxoid in incomplete Tetanus toxoid in incomplete

immunization immunization

hospitalizationhospitalization Extended of burn Extended of burn > 10% in children in children

Body surface area involved:Body surface area involved:Face ,neck, both hands, both feet ,prineumFace ,neck, both hands, both feet ,prineum

Type of burn; Type of burn; electrical contact ,chemicalelectrical contact ,chemical Association injuries;Association injuries;Soft tissue trauma, fractures,smoke inhalation Soft tissue trauma, fractures,smoke inhalation

head injury .head injury .

hospitalizationhospitalization Complicating medical problemsComplicating medical problems Diabetes ,heart disease, pulmonary disease, ulcer Diabetes ,heart disease, pulmonary disease, ulcer

history.history. Social problemSocial problem..Suspected child abuse or neglect, self infected Suspected child abuse or neglect, self infected

burn, psycologic problemsburn, psycologic problems

Burn ComplicationBurn Complication Sepsis ( avoid prophylactic antibiotic)Sepsis ( avoid prophylactic antibiotic) Hypovolemia, hypothermia Hypovolemia, hypothermia laryngeal edemalaryngeal edema carbon monoxide injurycarbon monoxide injury(100% o2,hyper baric o2)(100% o2,hyper baric o2) cardic disfunctioncardic disfunction gasteric ulcergasteric ulcer

Burn ComplicationBurn Complication compartment syndromecompartment syndrome contracturecontracture hyper metabolic statehyper metabolic state renal failurerenal failure anemiaanemia psychological traumapsychological trauma pulmonary infiltration,pulmonary pulmonary infiltration,pulmonary

edema, pneumonia,bronchospasmedema, pneumonia,bronchospasm