shock课件

Shock,Pediatric Emergency Medicine Cohen Childrens Medical Center,Shock,Pathophysiology review Definitions Compensated vs. Uncompensated Types of shock Review of drugs Treatment PALS ACCM Fluids Steroid Sedation,Definition,“Acute syndrome that occurs because of cardiovascular dysfunction and the inability of the circulatory system to provide adequate oxygen and nutrients to meet the metabolic demands of vital organs.”,Fleisher GR, et al. Textbook of Pediatric Emergency Medicine.,Trauma, AGE, Infections, Ingestions Shock Multiorgan system failure DEATH,Microcirculatory,Vasoconstriction Decreased hydrostatic pressure Endothelial damage Complement activation,Poor tissue perfusion Lack of oxygen Anaerobic metabolism ATP Lactate ACIDOSIS,Potassium efflux and Sodium influx Water influx Cellular dysfunction EDEMA,Vasoactive Mediators,Severe vasoconstriction Vasospasm Platelet aggregation Thrombus formation capillary permeability blood flow to vital organs,Nitric Oxide,Biochemical mediators Increased NO production Vasodilation Vascular hyporesponsiveness Hypotension Shock,Inflammatory Mediators,Induce fever Increase WBCs Cellular aggregation Increased endothelial cell production of Procoagulant molecules Cell adhesion molecules Increased vascular permeability,ACCM Definitions of Shock,Brierley, J, et al Clinical practice parameter Crit Care Med 2009,Cold Shock,Decreased perfusion Altered mental status Urine out 2 sec Diminished pulses Mottled, cold extremities,Warm Shock,Decreased perfusion Altered mental status Urine output 1 ml/kg/hr Flash capillary refill Bounding peripheral pulses Warm extremities,Fluid-refractory / Dopamine-resistant shock,Shock persists s/p 60 ml/kg fluids Dopamine 10 mcg/kg/min,Catecholamine-resistant Shock,Shock persists s/p Direct-acting catecholamines Epinephrine Norepinephrine,Refractory Shock,Shock persists s/p Inotropic agents Vasopressors Vasodilators Maintenance of calcium and glucose Hormonal homeostasis Thyroid Hydrocortisone Insulin,Case,5 yo male p/w 3 days fever and not acting like himself as per mom. Some vomiting and diarrhea. Vitals T 38.5 C HR 180 BP 90/60 RR 26 General sleepy but arousable Cap refill 2-3 seconds Lungs - CTA b/l Heart - Regular heart rhythm, increased rate Abd soft, ND, NT,This patient is:,In compensated shock In decompensated shock Not in shock,This patient is:,In compensated shock In decompensated shock Not in shock,Compensated Shock,Hypovolemia,Absolute Loss of volume Vomiting, diarrhea, blood loss, third-spacing Functional Increased vascular capacity Sepsis, spinal cord injury, barbiturate overdose Cardiogenic Obstructive,Signs,Tachycardia Tachypnea 2-3 sec capillary refill Orthostatic Mild irritability,Uncompensated Shock,Signs,Tachycardia Tachypnea (worsens w/ acidosis) Mottled, cold skin Cap refill 4 seconds Hypotension,Hypoperfusion,Renal Oliguria CNS Agitation Confusion Coma GI Decreased motility,Types of Shock,Hypovolemic Distributive Cardiogenic Obstructive,Hypovolemic Shock,Blood Trauma Intracranial hemorrhage Vomiting Diarrhea Plasma Burns Hypoproteinemia Peritonitis Water Glycosuric diuresis Sunstroke,Distributive Shock,Anaphylaxis CNS / spinal injuries Ingestions Sepsis,Cardiogenic Shock,Myocarditis Arrhythmia Drug ingestions Post-op cardiac Metabolic abnormalities Congenital heart disease,Obstructive Shock,Cardiac tamponade Tension pneumothorax,Vasopressors / Inotropes,Receptors,1 Inotropic (contractility) Chronotropic (rate) Dromotropic (increased conduction) 2 Vasodilation Bronchial smooth muscle relaxation,Receptors, Arteriole constriction Bronchial muscle constriction Dopaminergic (DA1 and DA2) Smooth muscle relaxation Increase renal blood flow Sodium excretion,Dopamine,Dose 2-20 mcg/kg/min Mechanism 1, 2, DA stimulation Inotrope Vasopressor Increases renal blood flow 1-2 mcg/kg/min Increases cardiac output 5-10 mcg/kg/min,Epinephrine,Dose 0.1-1.0 mcg/kg/min Mechanism 1, 2, stimulation Inotrope Vasopressor 0.3 mcg/kg/min has effects,Dobutamine,Dose 2.5-15 mcg/kg/min Mechanism 1, 2 stimulation Inotrope 1yo do not respond,Norepinephrine,Dose 0.1-1.0 mcg/kg/min Mechanism , 1 stimulation Vasopressor Concern Renal vasoconstriction,Milrinone,Dose Bolus: 50-75 mcg/kg over 10-60 min Drip: 0.5 0.75 mcg/kg/min Mechanism Phosphodiesterase inhibitors Inodilator Effect Decrease afterload Improved coronary artery blood flow Improved contractility,Pure Vasodilators,Nitroglycerin Nitroprusside Mechanism Reduces afterload Reduces venous tone,Pure Vasoconstrictor,Vasopressin Mechanism Increases systemic vascular resistance,Treatment,Septic Shock PALS recommendations Fluids Steroids Sedation Other Shock,ABCs according to PALS guideline,20ml/kg boluses Correct hypoglycemia/hypocalcemia Antibiotics Consider vasopressors/steroid,Responded to fluids,Consider ICU,Start vasopressor NL BP = dopamine BP (warm) = norepinephrine BP (cold) = epinephrine,Yes,No,SEPTIC SHOCK,60 minutes,Evaluate Scvo2,Scvo2 70%, BP “warm shock”,Scvo2 70%, NL BP Poor perfusion,Scvo2 70%, BP “cold shock”,More fluid Norepinephrine +/- vasopressin,More fluid Transfuse Hgb 10 Consider milrinone or nitroprusside Consider dobutamine,Transfuse Hgb 10 Consider epinephrine or dobutamine + norepinephrine,If adrenal insufficiency suspected: *Fluid refractory and vasopressor Hydrocortisone 2 mg/kg bolus dependent shock at risk of insufficiency,Airway Establish an airway Breathing Provide 100% FiO2 Support ventilation Circulation Immediate vascular access 20 cc/kg crystalloid fluid over MINUTES,Fluids,Fluids,Normal saline Ringers lactate PRBCs 10 ml/kg over 1-2 hours Keep Hgb 10 g/dL 5% albumin 10 ml/kg If Hgb 10 g/dL or no blood available,Fluid Administration,Preferred Push-pull Pressure bag Other Gravity Pump,Fluid Overload,Signs Increased work of breathing Rales Gallop rhythm Hepatomegaly 10% body weight Treatment Diuretics Dialysis Continuous Renal Replacement Therapy (CRRT) CVVH or CVVHD,PALS,20 ml/kg over 5-10 minutes Hypovolemic Distributive Obstructive 5-10 ml/kg over 10-20 minutes Cardiogenic,Antibiotics,Immediate administration Obtain cultures first if possible Broad spectrum Ceftriaxone +/- Vancomycin,Steroids,Recommendations changed many times over years Remains controversial Risk Purpura fulminans CAH Recent steroids Hypothalmic Pituitary abnormality,PALS,Adrenal insufficiency Fluid-refractory and Dopamine or norepinephrine-dependent Random cortisol 18 mcg/dL ACTH stimulation test cortisol 10 mcg/dL after 30 or 60 minutes Hydrocortisone 2 mg/kg bolus (max 100mg),Sedation in Sepsis,Etomidate,Cardiovascular stability Increased mortality in septic shock Inhibition of adrenal cortisol biosynthesis Transient inhibition 11-hydroxylase response to exogenous cosyntropin Studies have mixed results with different interpretations,Sprung CL, et al. Hydrocortisone therapy. NEJM. 2008 Lipiner-Friedman D, et al. Adrenal function in sepsis. Crit Care Med. 2007,Ketamine,Preferred Consider pretreating with atropine Benzodiazepines for continued sedation Recommended by ACCM Cardiovascular stability NMDA receptor blocker Reduces IL-6 Maintains intact adrenal axis,Other Sedation,Myocardial depression Vasodilatory effects Propofol, thiopental, benzoes, inhaled agents,Treating Other Shock,Case,3 yo female p/w vomiting and diarrhea for two days. As per mom she has not urinated since last night. Vitals: T 37 C HR 150 BP 76/40 RR 24 Awake, but decreased alertness Lungs - CTA b/l CV - reg rhythm, no murmur, cap refill 3 sec Abd no HSM, soft, ND, NT,Your first choice of fluids is?,10 cc/kg NS over 60 minutes 10 cc/kg NS rapid infusion 20 cc/kg NS over 60 minutes 20 cc/kg NS rapid infusion,Your first choice of fluids is?,10 cc/kg NS over 60 minutes 10 cc/kg NS rapid infusion 20 cc/kg NS over 60 minutes 20 cc/kg NS rapid infusion,Hypovolemic Shock,VOLUME VOLUME VOLUME 20 ml/kg boluses of isotonic crystalloid x3 PRBCs 10 ml/kg “third spacing” Colloid Albumin 0.5 1.0 g/kg (10-20 ml/kg of 5%),Case,A 5 yo male p/w sudden onset of respiratory distress as per mom. The patient is noted to have diffuse urticaria and wheezing on exam. His cap refill is noted to be 2-3 seconds.,Which medication(s) should be given immediately?,Albuterol Epinephrine Benadryl All of the above,Which medication(s) should be given immediately?,Albuterol Epinephrine Benadryl All of the above,Anaphylactic Shock,Epinephrine (1:1000) 0.01 mg/kg IM Q15 min Max dose: 0.3 mg 0.1 -1 mcg/kg/min IV (1:10,000) 0.01 mg/kg IV/IO (hypotension) Albuterol PRN H1 blocker H2 blocker Corticosteroids Solumedrol 2 mg/kg/dose,Case,10 yo male present s/p pedestrian struck. The accident was unwitnessed. The patient is unconscious. His vitals are: T 35 C HR 65 BP 80/40 RR 22 Neuro unable to elicit reflexes in LE,You are concerned this patient is in what type of shock?,Cardiogenic Neurogenic Hypovolemic Septic,You are concerned this patient is in what type of shock?,Cardiogenic Neurogenic Hypovolemic Septic,Neurogenic Shock,Hypotension / bradycardia / hypothermia Patient flat or trendelenberg Fluids Vasopressors Epinephrine Norepinephrine Warming or cooling Steroids,Case,A 1 yo female p/w lethargy and increased work of breathing x 2 days. On exam she has diffuse rales and retractions. Heart sounds are difficult to assess secondary to tachycardia. Her capillary refill is 3-4 seconds.,Your first choice of volume is?,PRBCs 10cc/kg NS 20cc/kg NS 10cc/kg PRBCs 20cc/kg,Your first choice of volume is?,PRBCs 10cc/kg NS 20cc/kg NS 10cc/kg PRBCs 20cc/kg,Cardiogenic Shock,Fluids 5-10 ml/kg over 10-20 minutes Diuretics Pulmonary edema Systemic venous congestion Vasodilators Milrinone Reduce metabolic demand Ventilatory support Antipyretics,Obstructive Shock,Treat the cause Tension pneumothorax Needle decompression Chest tube insertion Cardiac Tamponade Pericardiocentesis,References,Stoner, MJ, et al. Rapid fluid resuscitation in pediatrics: Testing the American College of Critical Care Medicine guideline. Ann of Emerg Med. 2007; 50(5): 601-607 Santhanam, I, et al. A prospective randomized controlled study of two fluid regimens in the initial management of septic shock in the emergency department. Ped Emerg Care. 2008; 24(10): 647-655 Absalom A, et al. Adrenocortical function in critically ill patients in 24 hours after a single does of etomidate. Anaesthesia. 1999; 54: 861-867 Mohammad Z, et al. The incidence of relative adrenal insufficiency in patients with septic shock after the administration of etomidate. Crit Care. 2006; 10: R105 Brinker M, et al. Adrenal insufficiency in meningococcal sepsis: bioavailable cortisol levels and impact of interleukin-6 levels and intubation with etomidate on adrenal function an