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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?.

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Recognizing Shock

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  1. RecognizingShock

  2. 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

  3. 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

  4. What is Shock? What are the results of shock? • Tissue hypoxia/cellular dysfunction • Metabolic acidosis • Organ dysfunction/failure • DEATH

  5. What is Shock? • For each hour that shock persists without treatment, the mortality rate goes   !

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

  7. 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

  8. General appearance Capillary refill Pulses Vital signs Urine output Questions to ask Signs and Symptoms of Shock ASSESSMENT PARAMETERS

  9. Signs and Symptoms of Shock General Appearance • What does the patient look like? • Evaluate mental status

  10. Signs and Symptoms of Shock Capillary Refill • 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

  11. Signs and Symptoms of Shock

  12. Signs and Symptoms of Shock Is this a sign of poor perfusion?

  13. Signs and Symptoms of Shock • YES !!!!!

  14. Signs and Symptoms of Shock • Evaluate pulses Pulses

  15. 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 Signs and Symptoms of Shock

  16. Signs and Symptoms of Shock Vital Signs • Evaluate vital signs They are called vital signs because…..

  17. …….they are REALLY, REALLYimportant!!!!! Signs and Symptoms of Shock

  18. Signs and Symptoms of Shock • In order for vital signs to be helpful you need to know • Absolute number • Context or clinical scenario • Trends

  19. Signs and Symptoms of Shock • Absolute number • Is the number normal or abnormal?

  20. Signs and Symptoms of Shock • 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.)

  21. Signs and Symptoms of Shock • Trends • Are the vital signs: • Improving? • Stable? • Deteriorating?

  22. Signs and Symptoms of Shock • Stable means • Unchanging or static • It does not automatically mean normal or good • Remember, death is a stable state!

  23. Signs and Symptoms of Shock • 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?

  24. Signs and Symptoms of Shock • 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)

  25. AGE WT. (KG) PULSE RESPIRATORY RATE SYSTOLIC BP 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 PEDIATRIC VITAL SIGNS REFERENCE CHART  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)

  26. Signs and Symptoms of Shock • 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

  27. Signs and Symptoms of Shock • 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

  28. Hemodynamic Response to Shock 140 100 60 20 Vascular Resistance • 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 Percent of control Blood Pressure CardiacOutput Decompensated or Late Shock Compensated or Early Shock

  29. Signs and Symptoms of Shock • 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

  30. Signs and Symptoms of Shock Urine Output • Evaluate urine output • Urine output is a good indicator of renal perfusion, but do not use the initial measurement of urine

  31. Signs and Symptoms of Shock • How to calculate normal urine output

  32. Signs and Symptoms of Shock • 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?

  33. 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

  34. Types of Shock • Septic shock has three components: • Systemic inflammatory response • Infection • Poor perfusion and hypotension

  35. Types of Shock • Systemic Inflammatory Response Syndrome • > 2 of the following: • Abnormal temperature • Tachycardia • Tachypnea or respiratory alkalosis • Abnormalities of WBC

  36. EARLY Signs of inadequate tissue/organ perfusion Normal BP LATE Signs of inadequate tissue and/or organ perfusion Hypotension Types of Shock PHYSIOLOGIC CLASSIFICATION OF SHOCK

  37. Types of Shock • Irreversible Shock • Complete failure of the body’s compensatory mechanisms • Death occurs even in the presence of resuscitation measures

  38. Types of Shock • Early Shock What will the body do to try and compensate?

  39. 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

  40. 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

  41. 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

  42. Interventions/Treatments • Provide O2 and mechanical ventilation • FLUID RESUSCITATION 20ml/kg NS boluses (note the plural) • Vasoactive infusions (ie. dopamine) • Treat metabolic abnormalities

  43. Interventions/Treatments • 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

  44. Interventions/Treatments • Clinical Pearls • Know and look for these early warning signs • ↑HR - the most commonly ignored abnormal vital sign is tachycardia • Peripheral perfusion abnormalities • dBP – look for diastolic hypotension and look at the pulse pressure

  45. Interventions/Treatments • You MUST do FREQUENT, RAPIDREASSESSMENTSof the patient’shemodynamic status and DOCUMENT everything!

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

  47. 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

  48. 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!

  49. 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

  50. SHOCK – Reference Chart

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