Rismala Dewi

Pediatric Critical Care Division

Department of Child Health Cipto Mangunkusumo Hospital
Faculty of Medicine University of Indonesia
Jakarta

What is Shock?
A state in which there is inadequate tissue
perfusion to meet metabolic demands

It is not LOW BLOOD PRESSURE !!!

It is HYPOPERFUSION..

An Approach to Shock

BP = CO x SVR
BP = blood pressure
CO = cardiac output
SVR = systemic vascular resistance

An Approach to Shock
If the blood pressure is low, then either the:

CO is low
or
SVR is low

What are factors of CO?

CO = HR x SV
CO = cardiac output
HR = heart rate
SV = stroke volume

Factors of SV
Preload
Contractility
Afterload

Oxygen Delivery
DO2 = CO x CaO2 x 10

Remember: CO depends on HR, preload,

afterload, and contractility
CaO2 = Hb x 1.34 x SaO2 + (PaO2 x 0.003)

Remember: hemoglobin carries > 99% of

oxygen in the blood under standard conditions

Hemodynamics

Myocardial
Contractility
Stroke Volume
Cardiac Output
Blood
Pressure

Afterload

Heart Rate
Systemic Vascular
Resistance

Preload

Can cause your

blood pressure

to rise

Stages 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
inadequate perfusion of vital organs; irreparable
damage; death cannot be prevented

Types of Shock
Cor
Conduit
Content
*If anything
goes wrong
it must be one
of this

Classifications
Hypovolemic or Hemorrhagic
Cardiogenic

Obstructive
Distributive

Hypovolemic
# 1 cause of death in children worldwide

Causes
Water Loss (diarrhea, vomiting with poor PO

intake, major burns), blood Loss, trauma

Low preload: leads to SV and CO

Compensation: occurs with HR and SVR

Diagnosis
Shock is a clinical physiologic
diagnosis
Early diagnosis requires a high
index of suspicion
Diagnosis is made through the
physical examination focused on
tissue perfusion

Clinical features
Pediatric Assessment Triangle

Circulation

Clinical features
Neurological: fluctuating mental status,
sunken fontanel
Cardio-pulmonary: tachypnea, tachycardia
Skin and extremities: cool, pallor, mottling,
cyanosis, poor cap refill, weak pulses
Renal: scant, concentrated urine

hypotension is a late
and premorbid sign

Laboratory findings
Acidosis on blood gas analysis with a base
deficit
Decreased mixed venous oxygen saturation
Electrolyte abnormalities

Management

Management
Always begin with ABCs
Airway: must be patent, adequately
oxygenated and ventilated
Breathing: always provide suplemental
oxygen
Circulation: vascular access, volume
expansion

Management (after ABCs)

Goals
Restore intravascular volume
Correct metabolic acidosis
Treat the cause

Management (after ABCs)

Mainstay of therapy is fluid
Fluid challenge
Fluid loading
Fluid replacement
Fluid maintenance

Management (after ABCs)

Isotonic crystalloid is always a good choice
20 to 50 cc/kg rapidly if cardiac function is
normal
Degree of dehydration often underestimated
Reassess perfusion, urine output, vital signs

Management (after ABCs)

Treat underlying cause

Correct acidosis
Inotropic and vasoactive drugs: select to

optimized desire effect

Remember!!!!
Shock is not something that is broke
that you fix and are done
so.dont forget
to monitor the patient

Key points

Recognize compensated shock quickly-have

a high index of suspicion, remember
tachycardia is first sign
Hypotension is late and ominous
Initial priorities are for the ABCs
Successful resuscitation depends on early
and judicious intervention

Administer adequate amounts of fluid

rapidly, remember ongoing losses

Correct electrolytes and acidosis problems
quickly
Monitoring is important thing

Questions To Run On

What insights have you gained from

todays presentation?

What actions will you take based upon

what you have heard?

Case Study
A 9 month-old girl presents with a one day
history of irritability and fever
Mother reports three days of bad vomiting
and diarrhea
Home meds: ibuprofen for fever
PE: BP 80/40, HR 200, R 60, T38.3 C
Irritable, sunken eyes and fontanel, cool and
cyanosis

Question are?
What else do you want to know?

What is the most likely diagnosis for these

findings?

What diagnostic study would you order?

How would you treat this patients?

How do you monitor the child improvement?

Thank You for Listening !!!