Shock in Pediatrics
Definition : shock is an acute process characterized by the body's inability to deliver adequate oxygen to meet the
metabolic demands of vital organs and tissues
Physiology
↓ tissue perfusion → cell anoxia → multiple organ failure → death
• Initially → reversible
• Prolonged → generalized tissue hypoxia + derangement of critical biochemical processes (including the release of
cytokines TNF, IL1) → irreversible → multiorgan failure → death
• Oxygen Delivery
DO2 = CaO2 x CO
CaO2 = (Hgb x 1.34 x SaO2) + (0.003 x PaO2)
CO = HR x SV (preload, contractility, afterload)
BP = CO x SVR
Pathophysiology
• Compensated Shock = initial insult triggers of shock → inadequate oxygen delivery → ↑ CO & SVR (to maintain BP)
→ optimize oxygen delivery to the tissues
Cardiovascular ↑ HR, SV, vascular smooth muscle tone, splanchnic vascular resistance
compensation
Respiratory compensation Greater CO2 elimination (in response to metabolic acidosis) + ↑ CO2 production
from poor tissue perfusion
Renal compensation Renal excretion of H+ ions + ↑ retention of HCO3 (maintain body pH)
Maintenance of Na regulation through the RAAS + atrial natriuretic factor axes, cortisol, and
intravascular volume catecholamine synthesis and release, and ADH secretion
• Decompensated Shock
Evaluation
, Evaluation
• The goals of initial evaluation of shock in children:
- Immediate identification of life-threatening conditions
- Rapid recognition of circulatory compromise
- Early classification of the type and cause of shock
• General Assessment: Pediatric Assessment Triangle (PAT)
Normal RR
-Newborn-1 year = 30-60 breaths/mins
-1-3 years = 25-40 breaths/mins
-3-12 years = 20-30 breaths/mins
->12 years = 12-20 breaths/mins
Normal HR
- Newborn = 80-200 beats/mins
- <2 years = 80-180 beats/mins
- 2-10 years = 60-150 beaths/mins
- >10 years = 60-100 beats/mins
• History (to identify the cause of shock)
- History of fluid loss
- Fever/immunocompromised
- Exposure to an allergen
- Exposure to toxins
- Patient with chronic heart disease
- Receiving chronic steroid therapy
• Physical Examination
- An accurate weigth and height
- RR → children with shock are usually tachypneic
- BP
○ Narrow pulse pressure = hypovolemic/cardiogenic shock
○ Wide pulse pressure = distributive shock
- HR → sinus tachycardia is consistent sign of shock, except with cardiogenic shock from bradycardia/spinal cord
injury (neurogenic shock)
- Temperature → fever or hypothermia is often consistent with septic shock
- Skin changes → cool, clammy, pale, mottled
Definition : shock is an acute process characterized by the body's inability to deliver adequate oxygen to meet the
metabolic demands of vital organs and tissues
Physiology
↓ tissue perfusion → cell anoxia → multiple organ failure → death
• Initially → reversible
• Prolonged → generalized tissue hypoxia + derangement of critical biochemical processes (including the release of
cytokines TNF, IL1) → irreversible → multiorgan failure → death
• Oxygen Delivery
DO2 = CaO2 x CO
CaO2 = (Hgb x 1.34 x SaO2) + (0.003 x PaO2)
CO = HR x SV (preload, contractility, afterload)
BP = CO x SVR
Pathophysiology
• Compensated Shock = initial insult triggers of shock → inadequate oxygen delivery → ↑ CO & SVR (to maintain BP)
→ optimize oxygen delivery to the tissues
Cardiovascular ↑ HR, SV, vascular smooth muscle tone, splanchnic vascular resistance
compensation
Respiratory compensation Greater CO2 elimination (in response to metabolic acidosis) + ↑ CO2 production
from poor tissue perfusion
Renal compensation Renal excretion of H+ ions + ↑ retention of HCO3 (maintain body pH)
Maintenance of Na regulation through the RAAS + atrial natriuretic factor axes, cortisol, and
intravascular volume catecholamine synthesis and release, and ADH secretion
• Decompensated Shock
Evaluation
, Evaluation
• The goals of initial evaluation of shock in children:
- Immediate identification of life-threatening conditions
- Rapid recognition of circulatory compromise
- Early classification of the type and cause of shock
• General Assessment: Pediatric Assessment Triangle (PAT)
Normal RR
-Newborn-1 year = 30-60 breaths/mins
-1-3 years = 25-40 breaths/mins
-3-12 years = 20-30 breaths/mins
->12 years = 12-20 breaths/mins
Normal HR
- Newborn = 80-200 beats/mins
- <2 years = 80-180 beats/mins
- 2-10 years = 60-150 beaths/mins
- >10 years = 60-100 beats/mins
• History (to identify the cause of shock)
- History of fluid loss
- Fever/immunocompromised
- Exposure to an allergen
- Exposure to toxins
- Patient with chronic heart disease
- Receiving chronic steroid therapy
• Physical Examination
- An accurate weigth and height
- RR → children with shock are usually tachypneic
- BP
○ Narrow pulse pressure = hypovolemic/cardiogenic shock
○ Wide pulse pressure = distributive shock
- HR → sinus tachycardia is consistent sign of shock, except with cardiogenic shock from bradycardia/spinal cord
injury (neurogenic shock)
- Temperature → fever or hypothermia is often consistent with septic shock
- Skin changes → cool, clammy, pale, mottled
