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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
Signs and Symptoms of Shock
• What does the patient look like?– Evaluate mental status
General Appearance
Signs and Symptoms of Shock
• 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
Signs and Symptoms of Shock
Signs and Symptoms of Shock
Is this a sign of poor perfusion?
Signs and Symptoms of Shock
• YES !!!!!
Signs and Symptoms of Shock
• 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
Signs and Symptoms of Shock
They are called vital signs because…..
Vital Signs
• Evaluate vital signs
…….they are
REALLY, REALLY
important!!!!!
Signs and Symptoms of Shock
Signs and Symptoms of Shock
• In order for vital signs to be helpful you need to know
• Absolute number
• Context or clinical scenario
• Trends
Signs and Symptoms of Shock
• Absolute number
• Is the number normal or abnormal?
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.)
Signs and Symptoms of Shock
• Trends
– Are the vital signs:
• Improving?
• Stable?
• Deteriorating?
Signs and Symptoms of Shock
• Stable means
• Unchanging or static
• It does not automatically mean normal or good
• Remember, death is a stable state!
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?
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)
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
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
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
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
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
Signs and Symptoms of Shock
• Evaluate urine output
– Urine output is a good indicator of renal perfusion, but do not use the initial measurement of urine
Urine Output
Signs and Symptoms of Shock
• How to calculate normal urine output
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?
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
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
Interventions/Treatments
• 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
Interventions/Treatments
• 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