Undifferentiated shock (peds): Difference between revisions
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**Cold shock: [[epinephrine]] 0.05mcg/kg/min starting dose | **Cold shock: [[epinephrine]] 0.05mcg/kg/min starting dose | ||
***Can be safely given through good peripheral IV <ref>Ramaswamy KN1, Singhi S, Jayashree M, Bansal A, Nallasamy K. Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock. Pediatr Crit Care Med. 2016 Sep 23.</ref> | ***Can be safely given through good peripheral IV <ref>Ramaswamy KN1, Singhi S, Jayashree M, Bansal A, Nallasamy K. Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock. Pediatr Crit Care Med. 2016 Sep 23.</ref> | ||
**Warm shock: [[ | **Warm shock: [[norepinephrine]] 0.05mcg/kg/min to start | ||
*Empiric antibiotics for [[sepsis (peds)|sepsis]] | *Empiric antibiotics for [[sepsis (peds)|sepsis]] | ||
**Neonatal: [[Ampicillin]] 50mg/kg q8h + [[gentamicin]] 2.5mg/kg q24h + [[acyclovir]] | **Neonatal: [[Ampicillin]] 50mg/kg q8h + [[gentamicin]] 2.5mg/kg q24h + [[acyclovir]] | ||
Revision as of 19:08, 24 August 2019
Background
Important physiologic differences between pediatric and adult patients
Intravascular volume
- Newborns: larger total body water compared to adults (75% vs. 60%) with the majority of it being in the extracellular fluid (ECF) (~40% vs. 25%)
- Percentage of ECF decreases throughout childhood
- Large surface area to weight ratio --> younger kids may have more fluid losses from ECF and intravascular space with short illness/environmental exposure decreased preload
- May present profoundly volume depleted and need more aggressive volume repletion
Cardiovascular
- Infants have immature myocardial calcium regulation system, difficulty storing/releasing calcium highly dependent on extracellular calcium for contractility
- Check iCal, replete calcium earlier, do NOT give CCBs to infants with tachydysrhythmias
- Stiffer, less compliant myocardium in infants-->increasing heart rate is main compensatory means for increasing BP
- BUT higher resting heart rate--> less room to go up (e.g. adult with resting heart rate of 60 can double to 120 but a neonate doubling resting heart rate of 120 to 240 is not sustainable)
- Heavily rely on vasoconstriction, which can further decrease cardiac output
- Less beta-adrenergic receptors/sympathetic innervations + more dominant parasympathetics --> exaggerated vagal response
- Hypotension is a ‘’’late’’’ finding in shock!
Clinical Features
- Signs/symptoms of underlying pathology
Cold shock
- More common in children than in adults
- Poor cardiac output due to decreased stroke volume--> tachycardia to compensate
- Poor peripheral perfusion, increased SVR (vasoconstriction) to compensate-->
- Skin cold to touch
- Diminished pulses
- Mottled skin
- Cap refill >2s
- Narrow pulse pressure, eventually hypotension
- Signs and symptoms of end organ damage as blood shunted to vital organs
- AMS, tachypnea, nausea/vomiting, AKI, lactic acidosis
Warm shock
- Hyperdynamic state, with vasodilation and low SVR
- Results in end organ damage due to shunting of blood away from vital organs to periphery
- Findings thus include:
- Tachycardia
- Wide pulse pressure
- Bounding peripheral pulses
- Brisk cap refill
Differential Diagnosis
- Hypovolemia
- More common and more profound in peds
- hemorrhage,
dehydration (from nausea/vomiting, insensible losses due to heat illness_)
- Cardiogenic
- Obstructive
- Distributive
- Neurogenic shock
Sick Neonate
THE MISFITS [1]
- Trauma
- Heart
- Congenital heart disease
- Hypovolemia
- Endocrine
- Metabolic
- Sodium
- Calcium
- Glucose
- Inborn errors of metabolism
- Seizure
- Formula / feeding problems
- Intestinal Disasters
- Toxin
- Sepsis
Evaluation
Management
- Aggressive IVF
- remember hypovolemia may be more profound in peds
- 40-60mL/kg NS or lactated ringers rapid bolus (e.g push-pull)
- Vasopressors if remains hypotensive OR with poor perfusion (e.g. cool, poor cap refill) after volume resuscitation
- Cold shock: epinephrine 0.05mcg/kg/min starting dose
- Can be safely given through good peripheral IV [2]
- Warm shock: norepinephrine 0.05mcg/kg/min to start
- Cold shock: epinephrine 0.05mcg/kg/min starting dose
- Empiric antibiotics for sepsis
- Neonatal: Ampicillin 50mg/kg q8h + gentamicin 2.5mg/kg q24h + acyclovir
- Peds: *Extended-spectrum penicillin (e.g. piperacillin-tazobactam) ± aminoglycoside ± vancomycin OR3rd or 4th generation cephalosporin ± aminoglycoside ± vancomycin OR Carbapenem ± aminoglycoside ± vancomycin
- Consider corticosteroids if volume non-responsive
- Treat underlying condition!
- Treat hypoglycemia
Disposition
- NICU/PICU
See Also
External Links
References
https://rebelem.com/approach-to-the-critically-ill-child-shock/
- ↑ Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006 Feb;53(1):69-84, vi.
- ↑ Ramaswamy KN1, Singhi S, Jayashree M, Bansal A, Nallasamy K. Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock. Pediatr Crit Care Med. 2016 Sep 23.