Undifferentiated shock (peds): Difference between revisions
 
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{{Peds top}} [[undifferentiated shock]].''
==Background==
==Background==
Important physiologic differences between pediatric and adult patients
Important physiologic differences between pediatric and adult patients
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**Bounding peripheral pulses
**Bounding peripheral pulses
**Brisk cap refill
**Brisk cap refill
===Shock index===
*Shock Index Pediatric-Adjusted (SIPA)- see https://www.mdcalc.com/shock-index-pediatric-age-adjusted-sipa
*Useful in identifying shock in trauma patients


==Differential Diagnosis==
==Differential Diagnosis==
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**[[PTX]], [[PE]], [[tamponade]]
**[[PTX]], [[PE]], [[tamponade]]
*Distributive
*Distributive
**[[Sepsis (peds |sepsis]]
**[[Sepsis (peds)|sepsis]]
**[[Anaphylaxis]]
**[[Anaphylaxis]]
**[[Adrenal insufficiency]]
**[[Adrenal insufficiency]]
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==Evaluation==
==Evaluation==


==Management==
==Management==
*Rapid IV access
**IO if unable to obtain in <1min
*Aggressive [[IVF]]
*Aggressive [[IVF]]
**remember hypovolemia may be more profound in peds
**Remember hypovolemia may be more profound in peds
**40-60mL/kg NS or lactated ringers rapid bolus (e.g push-pull)
**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
*[[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
**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: [[norephinepherine]] 0.05mcg/kg/min to start
**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]]
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*Treat underlying condition!
*Treat underlying condition!
*Treat [[hypoglycemia (peds)|hypoglycemia]]
*Treat [[hypoglycemia (peds)|hypoglycemia]]
*Treat [[hypocalcemia]], consider giving empiric calcium as inotrope
*If suspect ductal-dependant [[congenital heart disease]]:
**[[PGE1]] 0.1mcg/kg/min IV/IO
**[[NS]] 10cc/kg
**[[Dobutamine]]
{{Vasopressor table}}
===Causes of non-response to vasopressors<ref>Anand Swaminathan, "Occult Causes of Non-Response to Vasopressors", REBEL EM blog, July 13, 2017. Available at: https://rebelem.com/occult-causes-of-non-response-to-vasopressors/.</ref>===
*[[Acidosis]]
**Dx: Blood gas, BMP
**Tx: treat underlying cause, consider bicarbonate gtt
*[[Hypothyroidism]]
**Dx: Clinical, TSH
**Tx: [[levothyroxine]]
*[[Anaphylaxis]]
**Dx: History
**Tx: [[Epinephrine]], [[methylene blue]], ECMO
*[[Adrenal insufficiency]]
**Dx: Clinical, cortisol level, [[hyperkalemia]] + [[hyponatremia]]
**Tx: [[Hydrocortisone]] 100-200mg
*[[Hypocalcemia]]
**Dx: ionized calcium, [[prolonged QTc]]
**Tx: [[Calcium chloride]] or [[calcium gluconate]]
*[[Hemorrhagic shock|Occult bleeding]]
**Dx: Clinical (consider [[GI bleed]] and retroperitoneal hematoma)
**Tx: Transfusion, treat coagulopathy, surgery/IR interventions
*[[Toxicology (main)|Toxicologic]]
**Dx: Clinical (consider [[beta blocker toxicity]], [[calcium channel blocker toxicity]], [[TCA overdose]], etc)
**Tx: Depends on etiology (glucagon, hyperinsulin euglycemia therapy, sodium bicarbonate, ECMO, etc)
*2nd cause of shock
**Dx: Clinical, consider [[RUSH exam]]
**Tx: Address underlying cause


==Disposition==
==Disposition==
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==References==
==References==
https://rebelem.com/approach-to-the-critically-ill-child-shock/
https://rebelem.com/approach-to-the-critically-ill-child-shock/
https://pedemmorsels.com/epinephrine-for-shock/
https://www.chop.edu/clinical-pathway/sepsis-emergent-care-clinical-pathway
<references/>
<references/>
[[Category:Pediatrics]] [[Category:Critical Care]]

Latest revision as of 21:05, 9 March 2021

This page is for pediatric patients. For adult patients, see: undifferentiated shock.

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

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

Shock index

Differential Diagnosis

dehydration (from nausea/vomiting, insensible losses due to heat illness_)

Sick Neonate

THE MISFITS [1]

Evaluation

Management

Vasopressors

Pressor Initial Dose Max Dose Cardiac Effect BP Effect Arrhythmias Special Notes
Dobutamine 3-5 mcg/kg/min 5-15 mcg/kg/min (as high as 200) [3] Strong ß1 agonist +inotrope +chronotrope, Weak ß2 agonist +weak vasodilatation ) alpha effect minimal HR variable effects. indicated in decompensated systolic HF, Debut Research 1979[4] Isoproterenol has most Β2 vasodilatory and Β1 HR effects
Dopamine 2 mcg/kg/min 20-50 mcg/kg/min β1 and NorEpi release α effects if > 20mcg/kg/min Arrhythmogenic from β1 effects More adverse events when used in shock compared to Norepi[5]
Epinepherine 0.1-1 mcg/kg/min + inotropy, + chronotropy
Norepinephrine 0.2 mcg/kg/min 0.2-1.3 mcg/kg/min (5mcg/kg/min) [6] mild β1 direct effect β1 and strong α1,2 effects Less arrhythmias than Dopamine[5] First line for sepsis. Increases MAP with vasoconstriction, increases coronary perfusion pressure, little β2 effects.
Milrinone 50 mcg/kg x 10 min 0.375-75 mcg/kg/min Direct influx of Ca2+ channels Smooth muscle vasodilator PDE Inhibitor which increases Ca2+ uptake by sarcolemma. No venodilatory activity
Phenylephrine 100-180 mcg/min then 40-60 mcg/min 0.4-9 mcg/kg/min Alpha agonist Long half life
Vasopressin Fixed Dose 0.01 to 0.04 U/min unknown increases via ADH peptide should not be titrated due to ischemic effects
Methylene blue[7] IV bolus 2 mg/kg over 15 min 1-2 mg/kg/hour Possible increased inotropy, cardiac use of ATP Inhibits NO mediated peripheral vasodilation Don't use in G6PD deficiency, ARDS, pulmonary hypertension
Medication IV Dose (mcg/kg/min) Concentration
Norepinephrine (Levophed) 0.1-2 mcg/kg/min 8mg in 500mL D5W
Dopamine 2-20 mcg/kg/min 400mg in 250 D5W
Dobutamine 2-20 mcg/kg/min 250mg in 250 mg D5W
Epinephrine 0.1-1 mcg/kg/min 1mg in 250 D5W

Causes of non-response to vasopressors[8]

Disposition

  • NICU/PICU

See Also

External Links


References

https://rebelem.com/approach-to-the-critically-ill-child-shock/ https://pedemmorsels.com/epinephrine-for-shock/ https://www.chop.edu/clinical-pathway/sepsis-emergent-care-clinical-pathway

  1. ↑ Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006 Feb;53(1):69-84, vi.
  2. ↑ 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.
  3. ↑ https://www.ncbi.nlm.nih.gov/pubmed/8449087
  4. ↑ Edmund H. Sonnenblick, M.D., William H. Frishman, M.D., and Thierry H. LeJemtel, M.D. Dobutamine: A New Synthetic Cardioactive Sympathetic Amine
  5. ↑ 5.0 5.1 De Backer Daniel et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. NEJM 363(9). 779-789
  6. ↑ https://www.ncbi.nlm.nih.gov/pubmed/15542956
  7. ↑ Pasin L et al. Methylene blue as a vasopressor: a meta-analysis of randomised trials. Crit Care Resusc. 2013 Mar;15(1):42-8.
  8. ↑ Anand Swaminathan, "Occult Causes of Non-Response to Vasopressors", REBEL EM blog, July 13, 2017. Available at: https://rebelem.com/occult-causes-of-non-response-to-vasopressors/.
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