HYPOVOLEMIC SHOCK

IN CHILDREN
Dr. B. Gebyar Tri B., SpA
- Medical Emergencies
- Main cause of death in children worldwide
( 6 20 million/year )
Developing Countries : Diarrheal illness
DHF
North Am& Europe : Blood loss ( trauma )
Dr Sutomo : 6 8% of total pediatric ED patients
Definition :
Circulatory system failure to supply oxygen and
nutrients to meet cellular metabolic demands
Pathophysiology :
Adequate circulatory function
depend on a combination of 3
major factors:

- Adequate blood volume

- Integrity and amintenace of
vasomotor tone

- Cardiac output ( Pump )

Pathophysiology :
Hypovolemia Compensatory Reflex Mechanism
- Baroreceptor
- Chemoreceptor
- Cerebral iaschemic receptor
- Humoral vasoactive substances
- Renal, salt, water
- Autotransfusion
Circul. Volume
Circulatory Volume
Preload
Stroke Volume
Cardiac Output
Baroreceptor, Chemoreceptor, Cerebral ischemic receptor
Cardio inhibitory center Cardiostimulatory center
Sympathetic output
Parasympathic output
Heart rate , Myocardial contractility
Vasoconstriction
Angiotensin, Vasopressin, Aldosteron
Autotransfusion
Effects of Defence Mechanism :
- Vasoconstriction : Cold Extremeties
Prolonged Cap. Refill
- Tachycardia
- Tissue perfussion : Anaerobic metabolism
Metabolic acidosis
- Arterio - venous O
2
& CO
2
different
Causes
1. Water - Electrolyte Loss : Diarrhea/ Vomiting
Diabetes Mellitus
Diabetes Insipidus
Heat stroke
2. Blood Loss
3. Plasma loss : Burns
Nephrotic Syndrome
Dengue Hemor. Fever

Clinical Manifestation
Depend on :
- Etiology of Shock
- Fluid loss ( quantities and rapidity )
- Duration and severity of shock
- Stadium of shock
Stadium of shock
IRREVERSIBLE
Inadequate perfusion of vital organs;
irreparable damage; death cannot be prevented
COMPENSATED
Blood flow is normal or increased and may be
maldistributed; vital organ function is maintained
UNCOMPENSATED
Mcrovascular perfusion is compromised; significant
reductions in effective circulating volume
Compensated Shock :
- Blood loss + 25%
- Tachycardia and weak pulse
- Pale, cold & clammy skin
- Capil refill > 3 second
- Systolic BP normal
- apathetic
- Tachypneu
Decompensated Shock :
- Blood loss 25 40 %
- Tachycardia ++,weak pulse ++
- Syst BP
- Capil Refill > 5 sec
- Cold & mottled skin
- Lethargy
Irreversible
- Blood loss > 40%
- Tachycardia++/ bradycardia/ pulseless
- BP
- Cold/deadly pale skin
- Sighing respiration
- Coma
Shock :
Diagnosis :
Hx/History of diare,Vomiting,trauma,allergies,heart dis., fever
Physical exam : Low BP ( less than 5
th
percentile )
Rapid and weak pulse/ pulseless
Cold and clammy skin/ mottled skin
Capillary refill > 3 sec
Decreased mental status
Decreased urine output
Laboratory studies : CBC, Glucose, electrolyte, BGA, ECG,RFT
Chest X ray
DD/ Etiology
Treatment
Airway management

Secure Airway
Always provide oxygen
Endotrachintubation & controlled ventilation is suggested
if respiratory failure or airway compromise is likely
- elective is safer and less difficult
- decrease negative intrathoracic pressure
- improved oxygenation and O
2
delivery and
decreased O
2
consumption
- can hyperventilate if necessary
Mainstay of therapy is fluid
- Aggressive volume resuscitation
- Goal directed therapies ( CI 3,3 6,0 ml/min/m
2
,
O
2
Consumption > 200ml/min/m
2
( Hb > 10 g% )
Circulation
Aggressive volume resuscitation decreased mortality from 58 %
( 1985 ) 18 % ( Pollack,1985; Ceneviva 1998 )
Large vol fluid for acute stabilization in childrenh have not been
shown to increase rate of ARDS ( Carcillo 1991, Zadrobilek 1989 ) or
cerebral edema ( Carcillo 1991, Powell 1990 )
Circulation
Based on presumed etiology
Rapid restoration of intravascular volume
IV - 60-90 seconds
I.O. if less than 4-6 years old
Central venous catheter
Use isotonic fluid : NS, LR, or 5% albumin
PRBCs to replace blood loss or if still
unstable after 60cc/kg of crystalloid
anemia is poorly tolerated in the stressed, hypoxic,
hemodynamically unstable patient
Fluid refractory shock Inotropics
Vasoactive/Cardiotonic Agents
Epinephrine
0.05-0.1 mcg/kg/min: mostly beta-1, some beta-2
> 0.1 to 0.2 mcg/kg/min: alpha-1
Dopamine
1-5 mcg/kg/min: dopaminergic
5-15 mcg/kg/min: more beta-1
10-20 mcg/kg/min: more alpha-1
may be useful in distributive shock
Dobutamine
2.5-15 mcg/kg/min: mostly beta-1, some beta-2
may be useful in cardiogenic shock
Norepinephrine
0.05-0.2mcg/kg/min : only alpha and beta-1
Use up to 1mcg/kg/min

Milrinone
50mcg/kg load then 0.375-0.75mcg/kg/min:
phosphodiesterase inhibitor; increased inotropy and
peripheral vasodilation ( greater effect on pulmonary
vasculature )

Phenylephrine
0.1-0.5mcg/kg/min: pure alpha
Metabolic Issues : A c i d B a s e
Advere effect : hyperosmolarity, hypocalcemia, hypernatremia,
left-ward shift of the oxyhb. dissociation curve
Na Bic 1-2 meq/kg or = 0.3 x weight (kg) x base deficit
Metabolic acidosis due to tissue hypoperfusion

Profound acidosis - depresses myocardial contractility
- impairs the effectiveness of
catecholamines
Tx: fluid administration and controlled ventilation
Buffer administration
Metabolic Issues
Electrolytes :

Calcium is important for cardiac function and for the
pressor effect of catecholamines

Hypoglycemia can lead to CNS damage and is needed for
proper cardiovascular function

Check the BUN and creatinine to evaluate renal function
Hyperkalemia can occur from renal dysfunction and/or
acidosis
Shock
BP , tachycardi
Capilarry refill > 2 sec
Decreased mental status
Oliguria/anuria
Secure Airway, Oxygenation
RL/Colloid 20 ml/kg/10 minute,
up to over 60ml/kg/ h
Fluid Responsive Fluid Refr. Shock
Cap. Refill < 2 sec
Urine > 1ml/kg/h
Observe in PICU
SaO
2
, Blood Glucose
BGA, ECG, Ca++
C V P
Inotropic
Fluid refractory-dopamine resistance
Epinephrine, N E, Vasodilator
Cathecolamine Resistance Shock
Adrenal Insufficiency +
C V P
Fluid
Adrenal Insufficiency -
Hydrocortisone
Evaluation
Circulation
Heart rate, BP, perfusion, and pulses, liver size
CVP monitoring may be helpful
Regardless of the cause: ABCs
First assess airway patency, ventilation, then
circulatory system
Respiratory Performance
Respiratory rate and pattern,
work of breathing, oxygenation (color), level of
alertness
Cardiovascular Assessment
Heart Rate
Too high: 180 bpm for
infants, 160 bpm for
children >1year old
Blood Pressure
Lower limit of SBP =
70 + ( 2 x age in years )
Peripheral Pulses
Present/Absent
Strength (diminished,
normal, bounding)
Skin Perfusion
Capillary refill time
Temperature
Color
Mottling
CNS Perfusion
Recognition of parents
Reaction to pain
Muscle tone
Pupil size
Renal Perfusion
UOP >1cc/kg/hr
Treatment
Solution Na+ Cl- K+ Ca++ Mg++ Buffer
NS 154 154 0 0 0 None
LR 130 109 4 3 0 Lactate
Plasmalyte 140 98 5 0 3 Acetate &
Gluconate
Inotropic and vasoactive drugs are not a substitute
for fluid, however...
- Can have various combinations of hypovolemic and
septic and cardiogenic shock
- May need to treat poor vascular tone and/or poor
cardiac function
Look for etiology of shock

Evaluate hemoglobin, hematocrit, and platelet count
should be followed as these values may drop after fluid
resuscitation

Shock from any etiology can lead to DIC and end organ
damage
CBC, PT, INR, PTT, Fibrinogen, Factor V, Factor VIII,
D-dimer, and/or FDPs Check LFTs, follow CNS
and pulmonary status
Think about inborn errors of metabolism

Lactate and pyruvate
Ammonium, LFTs
Plasma amino acids, urine organic acids
Urinalysis with reducing substances
Urine tox screen