Shock in children : The summary

           

SHOCK

Acute progressive syndrome with generalized inadequate perfusion and oxygen supply to fulfill metabolic demands. This is caused by either depletion of fluids, poor cardiac contractility or vasomotor imbalance.  Initially the condition is compensated by body’s sympathetic response, but later on may become decompensated with multi-organ failure.

Evaluation

·         H/o fluid loss like diarrhea, vomiting, burns, blood loss, polyuria, exposure to heat, reduced intake, congenital heart disease, infection, anaphylaxis, surgery

·         Anxious look, pallor, air hunger, sweating, irritability, drowsiness / coma, tachycardia, tachypnea, dry mucosa, cold extremities, mottling, prolonged capillary refill time > 3 sec, petechiae/ hemorrhagic rash.

·         Low urine output. BP stable initially, then starts falling.

·         Hepatomegaly, cardiomegaly and signs of CCF if cardiogenic shock due to arrhythmia or myocarditis.

·         Gallop rhythm, sinus tachycardia

·         CBC, blood sugar, s/Ca, Na, Cl, ABG

·         Chest X-ray, blood culture,

Management

• Admit in ICU or intensive care area within emergency / ward.
• Vital signs monitoring (TPR, BP, Saturation), capillary refill time
• Strict intake output measurement including daily weight. Catheterize bladder if required
• Stabilize Airway, Breathing, Circulation and Dextrose.
• Maintain airway by posture or airway insertion. Elevate foot end to improve circulation to vital organs.
• Insert two IV lines.
• Keep NPO. Aspirate stomach with NG tube.
• Keep warm. Use radiant heaters.
• Give Oxygen via nasal cannula, mask or head box. Correct hypoxia. May need intubation / ventilation.
• If hypovolemic shock, give 20 ml/kg Normal saline / Ringer Lactate as rapid push over 15 min. For refractory cases, repeat the same infusion two more times. Complete deficit therapy with total fluids 100 ml/kg over 4 hours.
• Correct Hypoglycemia (D10 2-4 ml/kg) and hypocalcemia (1-2 ml/kg calcium gluconate slow and dilute) as they frequently accompany shock in young infants.
• In refractory cases, give colloids like blood, plasma 10-20 ml/kg, Hemacel or salt free albumin 1-2 gm/kg slow
• Correct metabolic acidosis with sodium bicarb 1-2 ml/kg slow and dilute. Do blood gases, calculate base deficit and correct accordingly.
• Give Inotropic support like Dopamine 5-10 micro gm/kg/min and Dobutamine 10-20 micro gm/kg/min for cardiac support.
• Give steroids in the form of Hydrocortisone in stress doses or methyl prednisone IV (30 mg/kg)
• If shock is advanced and / or refractory, assess other systems (renal, cardiac, coagulation. GIT, respiration, metabolic) and manage for multiorgan failure. Consult seniors.