Management of Shock

in Children

DR. dr. Rismala Dewi Sp.A(K)

Pediatric Critical Care Division
Child health department FKUI-RSCM
Learning Objective

Type and clinical sign of shock in children

Management of shock

Guidelines for pediatric shock

Hemodynamics

Myocardial
Contractility

Stroke Volume Preload

Cardiac Output Afterload

Blood
Pressure Heart Rate
Systemic Vascular
Resistance
 Preload

Stroke
Cardiac Output Volume Contractility

Heart Rate

Afterload
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
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
 Shock is a clinical physiologic
diagnosis

Diagnosis is made through the physical

examination focused on tissue perfusion

Early diagnosis requires a high index

of suspicion

No Laboratory Test Diagnoses Shock

Management
 Treatment should be initiated
simultaneously with the identification
of probable cause of the shock state
Early Goals of Fluid Resuscitation

Normal heart rate

Normal pulses
Capillary refill time < 2 seconds
Normal blood pressure
Warm extremities
Normal mental status
Urine output >1 mL/kg/hr
 RISK

BENEFIT
Don’t give too much Fluid!!

Hepatomegaly
Rales
Increased WOB
↑Jugular venous pressure
Chest X-ray
USCOM
Echocardiography
Fluid responsiveness
Which drug?
-1 -2 
Dobutamine +++ + +
Dopamine ++ + Vary
Epinephrine ++ ++ +
Norepinephrine ++ 0 +++
Isoproterenol +++ +++ 0
 Goal Directed Therapy of Shock in Children
0 min
Recognize Pediatric Shock
Maintain airway, give oxygen, establish vascular access
Fluid resuscitation to achieve normal hemodynamic parameters and perfusion
5 min Stop if there are signs of fluid overloaded
Decrease VO2 (e.g. sedation, ventilator, normothermia, avoid convulsion)
Consider transfusion if Hb≪
Fluid Responsive Fluid Refractory Shock
15 min Monitor, diagnostic & Non Invasive diagnostic of hemodynamic status,
treatment guided treatment of inotrope, vasopressor, vasodilator
Normal BP, CI<3.3, Low BP, CI<3.3, Low BP, CI>6,
SVR>1500 SVR<800 SVR<800
-Give fluid if SVV≫ -Give fluid if SVV≫ -Give fluid if SVV≫
-Milrinone -Epinephrine -Nor epinephrine
-Consider
Norepinephrine

Cathecolamine Resistant Shock

60 min Try hydrocortison

Persistent Shock
Metabolic and hormonal therapy
17
Common location for intraosseous line
20
21
 Stable
Monitor Y hemodynamic?
N
Continue volume Volume
replacement Y responsive?
N

Cold extremities?

INOTROPIC VASOPRESSOR
Key points
Recognize compensated shock quickly-have a
high index of suspicion, remember tachycardia is
first sign and hypotension is late and ominous
Successful resuscitation depends on early and
judicious intervention
Administer adequate amounts of fluid rapidly,
remember ongoing losses
Monitoring is important thing