Emergency Room Management of

ShockDr Nishant Verma

Assistant ProfessorDepartment of Pediatrics, KGMU

© Nishant Verma

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Mortality rates increase according to the degree of hemodynamic abnormality at presentation to the

community hospital.

Carcillo JA et al. Mortality and Functional Morbidity After Use of PALS/APLS by Community Physicians. Pediatrics 2009;124;500

No shockTachycardiaShock

N = 4856

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Carcillo JA et al. Mortality and Functional Morbidity After Use of PALS/APLS by Community Physicians. Pediatrics 2009;124;500

Early reversal of any hemodynamic abnormality in the community hospital was associated with improved

outcome.

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A case scenario

A previously healthy 12yr boy complains of severe malaise

and shortness of breath. He describes onset of fever, pustular

skin lesions and left knee swelling 2 days prior to his arrival in

ER. O/E, he is alert but clearly ill and severely tachycardic (HR

160bpm). He has brisk capillary refill, bounding pulses and a

BP of 100/36 mmHg. He receives 250ml NS over 1hr and is

then transferred to PICU. On arrival he is noted to be

obtunded, with extremely poor perfusion and undetectable

BP. He is resuscitated with great difficulty and survives, albeit

with renal insufficiency.

Define Shock

Types of Shock

Stages of Shock

Assessment of Shock

Early Goal-directed management

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What is shock ?

Oxygen Delivery

Oxygen Demand

Oxygen Delivery = Arterial O2 content (CaO2) x Cardiac output (CO)

CaO2 = (Hb x 1.34 x SaO2) + (0.003 x PaO2)

CO = HR x Stroke volume

Stroke volume : Function of Preload, Afterload & Myocardial Contractility

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Stages of shockInitial Insult

Triggers shock

Decreased perfusion

Body’s compensatory mechanism

Compensated shock Decompensated shock

Tissue damage

Multisystem organ failure

Death

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Types of shock

Hypovolemic Shock

Distributive Shock

Cardiogenic Shock

Obstructive Shock

Septic Shock

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WarmWarm shock

TachycardiaFlushedBrisk capillary refillBounding pulsesWide pulse pressure

Cold shock

TachycardiaMottledDelayed refillThready pulsesNarrow pulse pressureHypotensionCold

+ Prognosis -

+ Cardiac Output -

+ Cardiac O

utput -

Stages of Septic shock

Assessment of a child in shock

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ABCD for any sick child in ER

Airway

Breathing

Circulation

Disability / Dextrose

Not able to maintain airwayNot breathing

GCS < 8

INTUBATE

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Hemodynamic assessment

GOALS

•Identify Shock

•Identify the type of shock

•Identify the stage of shock

•Monitor treatment response

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Assessment

VitalsHR, RR, Pulse vol, BPColor, CFT, Core-periphery temp diffPulse oximetryContinuous ECG

Adequacy of organ perfusionUrine output Mental statusArterial Lactate

Signs of overloadGallop rhythmHepatomegalyRales on auscultation

Focused history

Signs of dehydrationMucosa, eyes, skin turgor.

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Hypotension: a word of caution !

• Never wait for hypotension to set in

• Late sign in pediatric shock

• Indicates decompensated state

• Act as soon as you notice

– Tachycardia / Impaired perfusion

Management of Shock

15Crit Care Med 2009; 37:666–688

Emergency RoomManagement

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• Normal mental status

• Normal Peripheral perfusion (CFT < 3 s)

• Palpable distal pulses

• Normal blood pressure for age

• Urine output > 1ml/kg/hr

• Threshold HR

GOALS

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• Identify shock

• Begin oxygen

• Establish vascular access– IV– IO– Secure 2 lines

STEP 1 0 - 5min

FLUID BOLUS

INOTRPOES

Intra Osseous

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• Fluid resuscitation

– Fluid type – Crystalloids vs Colloids

– Amount – 20ml/kg boluses, push over 5-10 min

• Cautious in cardiogenic shock, newborns

– How much to give ?• Assess response after each bolus• Watch for signs of overload• Usually 40-60ml/kg

STEP 2 5-15min

Crystalloid NS/RL

20ml/kg 5-10min

Assess responseWatch for overload

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• Correct hypoglycemia• Correct hypocalcemia• Begin Antibiotics for suspected septic shock• If 2nd IV line available– Consider inotrope

STEP 2 5-15min

Shock not reversed

Fluid Refractory Shock© Nishant Verma

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Fluid Refractory Shock• Obtain central access (ketamine)• Start central inotrope

STEP 3 15-60min

Cold shock

Dopamine (5-20 mc

g/kg/min)

Adrenaline (0.05-1 mc

g/kg/min)

Warm shock

Norepinephrine (0.05-1

mcg/kg/min)

Shock not reversed

Catecholamine resistant Shock

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Catecholamine resistant shock• Consider Hydrocortisone– Indications

– Dose – 50mg/m2/day to 50 mg/kg/day

• Transfer to PICU

STEP 3 15-60min

Fluid-refractory, catecholamine-resistant shock and suspected or proven adrenal insufficiency

Stress dose

Shock dose

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Recognition, oxygen, access

Hydrocortisone if at risk for adrenal insufficiency

Rapid fluid boluses,glucose, antibioticsAdditional IV/intraosseous access

Secure airway, central accessBegin to titrate vasoactive agent

Titrate fluid resuscitation, inotropes with serial exams, supportive care until transport to PICU

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First Hour

Golden Hour of Shock Management

PICUManagement

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• CFT ≤2 s• Normal BP• Normal peripheral and central pulses• Warm extremities• Urine output > 1 mL/kg/hr, • Normal mental status• ScvO2 saturation > 70% • Cardiac index - 3.3 - 6.0 L/min/m2

Therapeutic end points

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• Establish arterial line

• Monitor CVP

– Attain normal MAP – CVP

• Monitor ScvO2

– Target > 70%

• Consider Mechanical ventilation

PICU management

Term NB – 55 mmHgUpto 1yr – 60 mmHg

2-15yr - 65 mmHg

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Inotropic and Vasoactive drugs Drug Inotropy Vasoconstriction Vasodilation

Dopamine +++(β1) (5-10mcg/kg/min)

++(ɑ)(>10mcg/kg/min)

-(D) (<2mcg/kg/min)

Dobutamine +++(β1)

- ++(β2)

Adrenaline +++ ++ +

Noradrenaline - +++ -

Vasopressin - +++ -

NTG/NTP - - +++

Milrinone +++ - ++

Enoximone +++ - +

Levosimendan +++ - +

INOTROPES

VASOPRESSORS

VASODILATOR

INODILATORS

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PICU management

Catecholamine resistant Shock

Cold shock with Normal BP

Cold shock with Low BP

Warm shock with Low BP

Maintain

Hb > 10

•Titrate fluid and epinephrine

•Consider vasodilators (NTG, Milrinone, Levosimendan)

•Titrate fluid and epinephrine

•If still hypotensive, consider norepi

•Consider inodilators

•Titrate fluid and norepinephrine

•If still hypotensive, consider vasopressin

•Consider low dose adre© Nishant Verma

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PICU management

Shock not reversed

Shock not reversed

Refractory shock:ECMO

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Supportive care

• Blood products

• Glycemic control

• Diuretics and renal replacement

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Questions

Case scenarios

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A 2-year-old previously healthy boy develops profuse diarrhea,

vomiting, and lethargy

Heart rate 176/min, blood pressure 78/60 mm Hg, respiratory

rate 40/min, temperature 96.7°F, SpO2 98%

Child arouses to needle sticks, is extremely mottled, and has

thready pulses

Clear lungs and precordium, abdomen is scaphoid and non-

tender

What is your impression?

What is your initial management?

Case 1

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Hypovolemic Shock

Start high flow oxygen

Achieve prompt IV or intraosseous access

Provide rapid bolus with isotonic crystalloid

Correct hypoglycemia if present

Provide additional fluid boluses as indicated,

consider possible ongoing losses

Case 1

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– A 3-week-old infant is evaluated for lethargy, poor feeding, rapidly

worsening appearance, and evolving respiratory distress

– Heart rate 190/min, blood pressure 60/46 mm Hg, respiratory rate

70/min, SpO2 95%, temperature 38.0°C (100.3°F)

– Mottled, thready upper extremity pulses, and cold lower extremities

– Lung fields have crackles and liver is enlarged

– Bedside glucose is 90 mg/dL, arterial blood gas shows a pH of 7.16 with a

pCO2 of 20 mm Hg. Ionized calcium is normal

What type of shock is this?

What is your management plan?

Case 2

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Cardiogenic Shock Due to Ductal-Dependent Lesion

ABCs with urgent vascular access

Evaluate response to small (5-10 mL/kg) fluid boluses

Begin prostaglandin infusion (0.05 mcg/kg/min) until

echocardiogram excludes duct-dependent congenital

heart disease

Support circulation with volume, inotropes as required

Urgent consultation with a cardiologist

Case 2

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– A 12-year-old 25kg inpatient with flu and knee pain collapses in his room. You are called to evaluate him in the pediatric ward

– Heart rate 168/min, respiratory rate 56/min, temperature 94.9°F, – BP 70/30 mm Hg, SpO2 96% on non-rebreather face mask– Barely responsive to painful stimuli– Skin mottled, distal pulses are imperceptible– Lungs are clear, without retractions– Unremarkable precordium and abdomen– Left knee is obviously inflamed– No urine output

What is your diagnosis?What is your plan of management ?Child receives 500ml NS over 30min. Is it appropriate ?

Transferred to PICU.After receiving 1000ml NS over 15min, develops hepatomegaly

and rales, still hypotensive, CFT>3, mottled.What next ?

Start DopaSecure central access, measure CVPStill in shock, what next ? Start Adrenaline

Case 3

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– A 16-month-old with cough presents in progressive respiratory

and cardiovascular failure

– The child is sedated, intubated, and ventilated. Heart rate

200/min, blood pressure 82/66 mm Hg, respiratory rate

32/min, temperature 37°C (98.5°F), SpO2 100% on 80% oxygen

– Skin is mottled, poor distal pulses

– Breath sounds are diminished on the right

– The abdomen is unremarkable

What additional study would you consider?

What is your management plan?

Case 4

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Obstructive Shock Needle aspiration with eventual chest tube placementFluid bolus administered (10-20 mL/kg of IV normal saline or lactated Ringer’s)Use caution with medications with the potential for vasodilation–Morphine

– Propofol

– Benzodiazepines

Case 4

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Key PointsRapid recognition of shock is essential to good outcomesDon’t wait for Hypotension to set inInitiate management of ABCs with particular attention to rapid fluid resuscitation, early antibiotics, and consider prostaglandin E in neonatesMore conservative with fluids in cardiogenic shock (5-10 mL/kg aliquots)Management should be directed at normalizing tissue perfusion and blood pressure (Goal directed)Frequent/Continuous monitoring as appropriateIf patient is not responding the way you think broaden your differential, think about other types of shock

“You may delay, but time will not.”

Benjamin Franklin

Thank You