recognizing shock

Recognizing

Shock

Objectives

• Know the definition of shock

• Recognize the signs & symptoms of shock

• Recognize that there are different types of shock

• Discuss interventions/treatment of shock

• Understand the differences in neonates

What is Shock?

• Shock is a clinical state in which the delivery of oxygen and substrates is insufficient to meet the demands of the body

What is Shock?

What are the results of shock?

• Tissue hypoxia/cellular dysfunction

• Metabolic acidosis

• Organ dysfunction/failure

• DEATH

What is Shock?

• For each hour that shock persists without

treatment, the mortality rate

goes !

What is Shock?

• In most cases of shock, the patient’s cardiac output is insufficient to adequately perfuse the body’s organs.

What is Shock?

• Goals in treating shock– Restore intravascular volume– Treat any myocardial dysfunction– Treat vascular insufficiency

• In order to– ↓ HR and ↑ BP

– Improve perfusion

– ↓ metabolic acidosis

– ↑ urine output

Signs and Symptoms of Shock

• General appearance

• Capillary refill

• Pulses

• Vital signs

• Urine output

• Questions to ask

ASSESSMENT PARAMETERS


• What does the patient look like?– Evaluate mental status

General Appearance


• Evaluate skin perfusion by checking capillary refill and skin color

• Capillary refill is evaluated by positioning the extremity just above the heart level, pressing a finger on the palm of the hand or the bottom of the foot, letting go and then counting how long it takes the color to return to the extremity

• Interpret capillary refill in conjunction with other signs of shock as it is a poor indicator when used alone

Capillary Refill


Is this a sign of poor perfusion?


• YES !!!!!


• Evaluate pulses

Pulses

Signs and Symptoms of Shock• How do you compare pulses???• Palpate peripheral & central pulses & compare

• Femoral & Pedal Or

• Brachial and Radial

• Are they ? • Weak /Thready• Normal• Bounding• Absent

• Note: A patient will lose peripheral pulses before they lose central pulses


They are called vital signs because…..

Vital Signs

• Evaluate vital signs

…….they are

REALLY, REALLY

important!!!!!



• In order for vital signs to be helpful you need to know

• Absolute number

• Context or clinical scenario

• Trends


• Absolute number

• Is the number normal or abnormal?


• Context

– What is the child doing?

(i.e., sleeping, playing, etc.)

– What is the clinical condition the child is in? (i.e., dehydration, fever, anemia, hypoxia, pain, anxiety, etc.)


• Trends

– Are the vital signs:

• Improving?

• Stable?

• Deteriorating?


• Stable means

• Unchanging or static

• It does not automatically mean normal or good

• Remember, death is a stable state!


• HEART RATE– You must evaluate the heart rate in the context

and clinical state of the child.

• Is he running around ?

• Is he febrile?

• Is he crying?


• HEART RATE– Rate normally decreases as child’s age

increases

– Tachycardia is the body’s response to stress

– Note normal ranges on Vital Sign Reference Sheet (see next slide)

AGE WT.(KG)

PULSE RESPIRATORYRATE

SYSTOLICBP

DIASTOLIC BP

BIRTH

2.7 - 4

100 – 180 35 50 – 70 16 – 36

1 MONTH

4 100 – 220 30 60 – 90 20 – 60

6 MONTHS

7 80 – 150 30 87 – 105 53 – 66

2 YEARS

12 - 14 80 – 150 25 95 – 105 53 – 66

4 YEARS

16 - 18 70 –110 23 95 – 105 53 – 66

6 YEARS

20 - 26 70 – 110 21 95 – 105 53 – 66

7 YEARS

20 - 26 70 – 110 21 97 – 112 57 – 71

8 YEARS

20 - 26 70 – 110 20 97 – 112 57 – 71

10 YEARS

32 - 42 55 – 90 19 97 – 112 57 – 71

ADOLESCENT

> 50 55 - 90 16 - 18 115 – 128 66 - 80

Normal Values:Systolic BP 1 to 7 years (age in years + 90)

8 to 18 years ( 2 x age in years + 83)

Diastolic BP 1 to 5 years (56)6 to 8 years ( age in years + 52)

PEDIATRIC VITAL SIGNS REFERENCE CHART


• HEART RATE

CO = HR X SV• CO = cardiac output (volume of blood ejected by the heart

each minute)• HR = heart rate• SV = stroke volume (volume of blood ejected per beat)

• The body attempts to compensate for a decreasing stroke volume by increasing the heart rate


• BLOOD PRESSURE• Measure systolic BP & diastolic BP

• Calculate pulse pressure (sBP – dBP = Pulse Pressure)• Why?… It is important to identify a widened pulse pressure

because it may be an early sign of shock.• If you wait to respond, it may result in a decrease in BP & narrow

pulse pressure

• Documenting “unable to obtain ” when measuring BP is unacceptable

Hemodynamic Response to ShockHemodynamic Response to ShockHemodynamic Response to ShockHemodynamic Response to Shock

Vascular Resistance

Blood Pressure

Cardiac

Output

Compensated or Early Shock

Decompensatedor Late Shock

140

100

60

20

Per

cent

of

cont

rol • BP = CO x VR

•As the CO ↓ the HR & VR ↑

• This enables the body to maintain a normal BP • THIS IS A KEY DIFFERENCE BETWEEN CHILDREN & ADULTS


• BLOOD PRESSURE– Hypotension typically develops before loss of

central pulses

– Hypotension is an ominous sign. If it is not treated promptly it will lead to cardiopulmonary failure/arrest


• Evaluate urine output

– Urine output is a good indicator of renal perfusion, but do not use the initial measurement of urine

Urine Output


• How to calculate normal urine output


Assessment Questions•Does my patient have normal perfusion?•What is the capillary refill?•How do the central and peripheral pulses compare?•What is the HR and BP? Is the patient improving?•What is my patient’s mental status?•Is my patient urinating? Is it adequate?

Types of Shock

• Hypovolemic Shock – inadequate intravascular volume - most common

• Cardiogenic Shock - characterized by myocardial dysfunction

• Neurogenic shock – characterized by nervous system dysfunction

• Anaphylactic shock – life threatening exposure to an allergen

Types of Shock

• Septic shock has three components:

• Systemic inflammatory response

• Infection

• Poor perfusion and hypotension

Types of Shock

• Systemic Inflammatory Response Syndrome

• > 2 of the following:

• Abnormal temperature

• Tachycardia

• Tachypnea or respiratory alkalosis

• Abnormalities of WBC

Types of Shock

• EARLY– Signs of inadequate

tissue/organ perfusion• Normal BP

• LATE– Signs of inadequate

tissue and/or organ perfusion

– Hypotension

PHYSIOLOGIC CLASSIFICATION OF SHOCK

Types of Shock

• Irreversible Shock– Complete failure of the body’s compensatory

mechanisms

– Death occurs even in the presence of resuscitation measures

Types of Shock

• Early Shock

What will the body do to try and compensate?

Types of Shock

• Have a catecholamine surge which results in….

• Tachycardia• ↑↑ systemic vascular resistance • Cool, pale, mottled skin• Capillary refill > 2 seconds• Weak, thready peripheral pulses

Types of Shock

• What else ?• Increased respiratory rate• Patient may be irritable, sleepy, lethargic• May see a decrease in urine output

• Blood pressure changes• Systolic is normal or even high• Diastolic may be low

Types of Shock

• Late/Decompensated Shock– Defense mechanisms begin to fail– The patient may exhibit:

• Hypotension• Prolonged capillary refill• Tachycardia or (bradycardia – ominous sign)• Absent peripheral pulses• Rapid, thready central pulses• Decreased level of consciousness

Interventions/Treatments

• Provide O2 and mechanical ventilation

• FLUID RESUSCITATION

20ml/kg NS boluses (note the plural)

• Vasoactive infusions (ie. dopamine)

• Treat metabolic abnormalities


• Clinical Strategies Know your patient’s history

Know normal vs abnormal and look for abnormalities

Know your patient’s vital sign trends

Think the “worst case scenario” and then rule it out


• Clinical PearlsKnow and look for these early warning signs

↑HR - the most commonly ignored abnormal vital sign is tachycardia

Peripheral perfusion abnormalitiesdBP – look for diastolic hypotension and look at the

pulse pressure


• You MUST do FREQUENT, RAPID REASSESSMENTS of the patient’s hemodynamic status and DOCUMENT everything!

Neonates

• If children are different from adults, then neonates are something else entirely.

Neonates

• Differences in the neonate• We are talking about patients with an

age of < 28 days

• Limited cardiac reserve

• Limited respiratory reserve

• Limited metabolic reserve

Neonates

• Take home message for neonates………

• Neonates can go into a shock state faster than children and adults.

• Neonates have less tolerance for shock states than children and adults.

• You must identify and treat shock immediately!

Message from Dr. Hernan

• Recognize shock and label it

• Rapidly and repeatedly assess hemodynamics

• Mortality is related to persistent shock

• Be appropriately aggressive with fluids and vasoactive infusions

• Intubate and mechanically ventilate early

• Remember the neonate

• Jump start the circulation or patients die

SHOCK – Reference Chart

EARLY LATE

Respiratory

Rate

Increased Increased

Bradypnea - ominous

Heart Rate Increased Increased

Bradycardia - ominous

Pulse Quality Decreased to thready

Bounding in Septic

Peripheral pulse may be absent Central decreased

Capillary Refill Prolonged >2 seconds Prolonged

LOC Normal to altered Altered mental status

BP Normal Hypotensive

Urine Output Decreased Anuric

REFERENCES:

Carcillo JA: Task force Members, Fields al. Clinical practice Parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 30(6):1-13, 2002

Hernan, Lynn J., MD, “Vital Signs” , “Recognition and Treatment of Pediatric Shock”

Kaleida Health Corporate Nursing Policy, Pediatric Vital Signs. PED.5PTC

PALS Provider Manual (2002). American Heart Association, Dallas, Texas AHA, PALS Instructor Manual, 2001

Whaley, Lucille F. and Wong, Donna L. (2003). Nursing Care of Infants and Children, 7th Edition, C.V. Mosby Company, St. Louis

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