CRISBERT I. CUALTEROS, M.D. - shock
   
DR. CRISBERT I. CUALTEROS
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  Clinical Practice Guidelines

CRISBERT I. CUALTEROS, M.D. Family and Medicine
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SHOCK

by:

CRISBERT I. CUALTEROS, MD

Shock

A clinical state characterized by

inadequate tissue perfusion resulting in oxygen and substrate delivery that is insufficient to meet tissue metabolic demands.

Types of Shock

According to Etiology:

Hypovolemic shock

Cardiogenic shock

Distributive shock

Hypovolemic Shock

Inadequate intravascular volume

relative to vascular space.

Causes:

diarrhea

vomiting

trauma

Cardiogenic Shock

Adequate intravascular volume

but cardiac dysfunction limits cardiac output.

Ex: myocarditis

Distributive Shock

Inappropriate distribution of blood

volume.

Causes:

Sepsis

Anaphylaxis

Neurogenic shock

Types of Shock

According to Its Effect on Blood Pressure:

Compensated shock

Decompensated shock

 

Signs of Shock:

Tachycardia

Mottled or pale color

Cool skin

Diminished peripheral pulses

Change in mental status

Oliguria

Delayed CRT

Types of Shock

According to Its Effect on Blood Pressure:

Compensated shock

Decompensated shock

 

P5 Systolic Blood

Pressure for Age

 

Age Systolic BP (p5)

0-1 month

60 mmHg

> 1 month to 1 yr 70 mmHg

>1 yr

- 10 yo (age in yrs x 2) + 70

> 10 yo 90 mmHg

 

Septic Shock

Inflammatory triad

Fever

Tachycardia

Vasodilation

Change in mental status

Inconsolable irritability

Lack of interaction with parents

Inability to be aroused

Clinical Diagnosis of

Septic Shock

Suspected infection

Decreased perfusion

Decreased mental status

Decreased urine output

Prolonged CRT or flash CR

Diminished or bounding

peripheral pulses

Mottled cool extremities

 

Objectives of Fluid

Resuscitation:

Rapidly restore effective circulating

volume in hypovolemic & distributive shock.

Restore oxygen-carrying capacity in

hemorrhagic shock states.

Correct metabolic imbalances

secondary to volume depletion.

Types of Fluids:

 

Crystalloids

Colloids

Blood Products

Crystalloids

Ex.: Lactated Ringer’s, normal

saline

Advantages:

Readily available

Inexpensive

No allergic reactions

Disadvantage:

Remain in intravascular

 

compartment for few minutes.

Crystalloids

Dextrose-Containing Solution:

Osmotic diuresis

Hypokalemia

Ischemic brain injury

Colloids

Ex.: Dextran, Haesteril,

Gelafundin

Advantage:

Remain in intravascular

compartment longer

Disadvantage:

Cause sensitivity reactions

Blood Products

Indications:

Replacement of blood loss

Correction of coagulopathies

Complications:

Blood-borne infections

Hypothermia

Blood Products

Recommended for fluid

replacement of volume loss in pediatric trauma victims with inadequate perfusion despite 2 to 3 boluses of crystalloid solution.

Administer:

10 to 15 ml/kg PRBC

20 ml/kg WB

Fluid Bolus

Administration

General guideline:

crystalloid solution very rapidly (over 5 to 20 minutes).

Fluid Bolus

Administration

If a child has severe signs of

 

hypovolemic shock (severe hemorrhage after trauma, severe dehydration), a 20 ml/Kg bolus is delivered rapidly (< 5 to 10 minutes).

Fluid Bolus

Administration

If the child demonstrates less

 

severe signs of shock or there is some impairment in cardiac function, a bolus of 10 ml/Kg is delivered over 10 to 20 minutes.

Fluid Bolus

Administration

If the child has severe

 

myocardial dysfunction (calcium channel blocker or ß-adrenergic blocker poisoning), smaller fluid boluses (5 to 10 ml/Kg) is delivered more slowly (over 10 to 20 minutes).

Drugs That Support

Cardiac Output

Inotropes

Vasopressors

Vasodilators

Inodilators

 

Drugs That Support

Cardiac Output

Inotropes

 

: increase cardiac contractility and heart rate.

Vasopressors

: increase vascular resistance and blood pressure

Drugs That Support

Cardiac Output

Vasodilators

 

: decrease vascular resistance and cardiac afterload and promote peripheral perfusion

Inodilators

: increase cardiac contractility and reduce afterload

Drugs That Support

Cardiac Output

Dopamine

Dobutamine

Epinephrine

Norepinephrine

Sodium nitroprusside

Milrinone

Dopamine

Indications:

blood flow and urine output

Dopamine

Dose: 2 to 20

μg/kg/minute

Infusion:

6 x body weight = mg to add to

diluent to create a total volume of 100 ml.

1 ml/hr delivers 1

μg/kg/min

Dopamine

Premixed solution:

Infusion rate (ml/hr):

=

weight (kg) x desired dose (μg/kg/min) x 60 min/hr

concentration (ug/ml)

 

200 mg/ 250 ml: conc 800 μg/ml

400 mg/ 250 ml: conc 1600 μg/ml

Dobutamine

Indications:

(elevated systemic or pulmonary vascular resistance)

Dobutamine

Dose: 2 to 20

μg/kg/minute

Infusion:

6 x body weight = mg to add to

diluent to create a total volume of 100 ml.

1 ml/hr delivers 1

μg/kg/min

Dobutamine

Premixed solution:

Infusion rate (ml/hr):

=

weight (kg) x desired dose (μg/kg/min) x 60 min/hr

concentration (ug/ml)

 

250 mg/ 250 ml: conc 1000 μg/ml

500 mg/ 250 ml: conc 2000 μg/ml

Epinephrine

Indications:

Epinephrine

Dose: 0.1 to 1

μg/kg/minute

Infusion:

0.6 x body weight = mg to be

added to sufficient diluent to create a total volume of 100 ml.

1 ml/hr delivers 0.1 μg/kg/min

Norepinephrine

Indications:

vasodilation)

Inadequate cardiac output

Spinal shock

α-adrenergic blockade

Norepinephrine

Dose: 0.1 to 2

μg/kg/minute

Infusion:

0.6 x body weight = mg to be

added to sufficient diluent to create a total volume of 100 ml.

1 ml/hr delivers 0.1 μg/kg/min

Sodium

Nitroprusside

Indications:

high systemic or pulmonary vascular resistance

Cardiogenic shock

Sodium

Nitroprusside

Dose: 1 to 8

μg/kg/minute

Infusion:

6 x body weight = mg to add to

diluent to create a total volume of 100 ml.

1 ml/hr delivers 1

 

μg/kg/min

Milrinone

Indications:

high systemic or pulmonary vascular resistance

Cardiogenic shock

Septic shock

Milrinone

Loading dose: 50 to 75

μg/kg

Infusion: 0.5 to 0.75 μg/kg/min

0.6 x body weight = mg to be

added to sufficient diluent to create a total volume of 100 ml.

1 ml/hr delivers 0.1 μg/kg/min

 

 

 

 

 

Thank

You !!!

Inadequate cardiac output with

Hypertensive emergencies

Inadequate cardiac output with

Hypotension (especially due to

Inadequate cardiac output

Hypotension

Symptomatic bradycardia

Pulseless cardiac arrest

Septic shock

Myocardial dysfunction

Inadequate cardiac output

Inadequate cardiac output

Hypotension

Need for enhanced splanchnic

Administer 20 ml/kg of isotonic

   

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