SHOCK!SHOCK RECOGNITION AND FIRST

STEPS

CHRISTOPHER S. AMATO, MD, FACEP, FAAP

MORRISTOWN MEDICAL / GORYEB CHILDREN’S HOSPITAL

MORRISTOWN, NJ

ENVISION PHYSICIANS GROUP

OBJECTIVES

Discuss myths and advantages/complications of standard peripheral line placement vs. IO placement vs. ultrasound guided line placement vs. UVC line in the neonate.

Discuss the use of goal-directed therapy in pediatrics.

Describe the assessment, treatment, and resuscitation of the pediatric patient in shock.

Illustrate new literature and the use of goal-directed therapy in pediatrics.

Review the thoughtful use of fluids in sepsis management.

READY…

…..Set….…IDENTIFY!!!

PUMP

TANK PIPES

LETS MAKE THIS SIMPLE

Insufficient circulating blood volume (preload)

Changes in vascular resistance (afterload)

Heart failure (contractility)

Obstruction to blood flow

IDENTIFICATION

https://www.google.com/search?biw=1600&bih=789&tbm=isch&sa=1&ei=JbRZXJLKLcGs5wKEnp7IBA&q=gif%2C+weakness%2C+disney&oq=gif%2C+weakness%2C+disney&gs_l=img.3...21715.26559..26941...1.0..0.153.945.5j4......1....1..gws-wiz-img.......0i8i30.N4g2qjBdOU0#imgrc=xkdqE-KfAP1PNM:

https://www.google.com/search?q=gif,+fatigue&tbm=isch&source=hp&sa=X&ved=2ahUKEwj-6ZOL_KTgAhVNzlkKHe2WBUoQsAR6BAgAEAE&biw=1600&bih=789#imgrc=VD8oPlRdVj1_YM:tps://www.google.com/search?q=gif,+fatigue&tbm=isch&source=iu&ictx=1&fir

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https://www.google.com/search?tbm=isch&sa=1&ei=ZbVZXNvbE-qb5wLBxKWIBA&q=dizziness+gif%2C+donald+duck&oq=dizziness+gif%2C+donald+duck&gs_l=img.3...35479.41511..41797...2.0..0.174.1620.1j12......1....1..gws-wiz-img.ioSW96YMPUY#imgdii=SMnkSbCDZip7KM:&imgrc=UHP9gmE5hOpJIM:

https://www.google.com/search?tbm=isch&sa=1&ei=kLVZXLH6C4mc5wKe_7q4BA&q=shock+gif%2C+minnie+mouse&oq=shock+gif%2C+minnie+mouse&gs_l=img.3...158851.168810..169217...1.0..0.188.3344.13j16......1....1..gws-wiz-img.......0i8i7i30j0j0i8i30.Pkszx5NOpLA#imgrc=vdgFTSZUAZ2eXM:

FATIGUEMALAISE

WEAKNESS

DIZZINESS

AMS/ Syncope

FEARFUL FINDINGS

Altered LOC

Tachypnea

Hypotension

INTRAOSSEOUS9

Pediatric Emerg Care. 2011 Oct;27(10):928-32.Intraosseous line use, complications, and outcomes among a population-based cohort of children presenting to California hospitals.Hansen M, Meckler G, Spiro D, Newgard C.Abstract450 California hospitals and Eds- 2005 - 2007All children aged 0 to 18 years with ED or inpt visits RESULTS: 291 IO lines placed in 90 hospitals (239 in the ED and 52 inpatient). 6,660,564 pediatric ED visits and 2,276,231 pediatric admissions, incidence of IO line placement of 0.04 per 1000 ED visits and 0.02 per 1000 admissions. Mortality 37% among patients with IOThe most common diagnoses included cardiac arrest (34%), trauma (19%), and respiratory failure (6%). No complications were identified.

INTRAOSSEOUS

STERNUM>>>>Proximal Humerus >>> FEMUR>>>>> Tibia

A comparison of proximal tibia, distal femur, and proximal Humerus infusion rates using the EZ-IO intraosseous device on the adult swine (Sus scrofa) model.Julio R Lairet, Vikhyat S Bebarta, +5 authors James KingPublished 2013 in Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Director

UMBILICAL VEIN??

https://www.google.com/search?biw=1600&bih=789&tbm=isch&sa=1&ei=mKZhXNWxAsGIggeBoojgDA&q=umbilical+line+placement+pediatric&oq=umbilical+line+placement+pediatric&gs_l=img.3...519184.524055..524343...0.0..0.200.1672.5j8j1......1....1..gws-wiz-img.3NpJ3P-GNV0#imgrc=eKyHXdWKsASbfM:

ACCESS

Vascular (venous) access for pediatric resuscitation and other pediatric emergencies - UpToDate

INTERNAL JUGULAR POSITIONING

Trendelenburg 15-30 degrees

Shoulder roll

Head turned away from side of insertion

INTERNAL JUGULAR

PROCEDURE

From Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013htt //bl b d / di i id /th t l li t 2 t h i d l t /

95% of people have some overlap of the femoral vein by femoral artery

By positioning the leg in an ABDUCTED & EXTERNALLY ROTATED Amount of overlap is reduced and

Diameter of the vein is increased

Maximizing the percentage of the vein available for cannulation

FEMORAL IJ/ Supraclavicular

PROS • Large Vessel = ↑ flow rate• Ease of placement• No risk of pneumothorax

• Tip placement in right atrium decreases recirculation

CONS • Risk for infection• ↓ flow if (+) ascites/increased

abdominal pressure

• Superior vena cava syndrome

• Risk of PTX esp. with high PEEP

WORK UP

Bio-Markers:

Lactate

Blood Glucose

Electrolytes

VBG vs. ABG

Sepsis pathways

RNA Biosignatures ?

CRP

Procalcitonin

IL-18

CD-64

Update on pediatric sepsis: a review. Tatsuya KawasakiEmail authorView ORCID ID profile. Journal of Intensive Care20175:47 https://doi.org/10.1186/s40560-017-0240-1 © The Author(s). 2017 Published: 20 July 2017

GOAL DIRECTED THERAPY

Hypotensive hypovolemic or distributive shock 20 mL/kg per bolus of isotonic crystalloid over 5 to 10

minutes

Repeat 4 times in patients without improvement and no signs of fluid overload

Blood products?

GOAL DIRECTED THERAPY

Median volume of fluid delivered over five minutes

Gravity 6.2 mL/kg

“Push-pull" 20.2 mL/kg

GOAL DIRECTED THERAPY

Median volume of fluid delivered over five minutes

“Push-pull" 20.2 mL/kg

Pressure bag 20.9 mL/kg

TO MUCH OF A GOOD THING

Cardiogenic shock

DKA

SIADH

Severe malnutrition

NORMAL SALINE

Saline Potential hyperchloremic non-gap acidosis

Balanced fluids Higher rates of renal injury – ADULTS

NNT 94

Lactated Ringers

Plasmalyte – another option

TARGETED END-POINTS

Improving quality of pulses

Improving blood pressure

Improving Skin perfusion

Improving level of consciousness

Urine output?? >1ml/kg/hour

VASOACTIVE MEDS

Major Traumatic Brain injury

Peri-intubation Hypotension

Post-arrest hypotension

The Use of Bolus-Dose Vasopressors in the Emergency DepartmentHolden D. et al. Ann Emerg Med 2018

REFRACTORY?

Antibiotics for sepsis (early in course)

Corticosteroids

Hydrocortisone bolus, using a dose of 50 to 100 mg/m2

Age-based dosing may be used as follows:

Infants and toddlers 0 to 3 years old: 25 mg IV

Children 3 to 12 years: 50 mg IV

Children and adolescents 12 years and older: 100 mg IV

STABILIZATION

A / B: Administer Oxygen but be cautions Titrate between 92-97% (after ROSC)

C: Get accessHumeral IO may be better then Tibia

Administer isotonic crystalloid - consider balanced solutions

Consider peripheral pressor until central access available

SUMMARY

Determine shock as quick as possibleVitals: Tachycardia, tachypnea, HYPOTENSION

Altered Mental status,

Urine output

Labs – Lactate – ensure 20% decreased within 2 hrs.

SUMMARY

Treat shock as quick as possible Fluids - Crystalloid

Peripheral pressor – likely start with Nor-epi

TARGETS

Improved perfusion / vitals

Improved pulses/ skin / cap refill <3

Decreasing lactate

QUESTIONS???

ACKNOWLEDGEMENTS

Michael Winters, MD, MBA

Timothy E Bunchman; Professor & Director; Helen DeVos Children’s Hospital, Grand Rapids, MI

Jennifer D. Walthall, MD, MPH