Shock

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CLINICAL DESCRIPTION

Acute circulation failure resulting in inadequate tissue perfusion and cellular hypoxia, generally with a low blood pressure.

This is a medical emergency which needs to be promptly treated.

Causes are;

• Hypovolemic {hemorrhage, cholera, severe vomiting, diabetic ketoacidosis}
• Cold, clammy skin; weak pulse,
• tachycardia
• Cardiogenic {myocardial infarction, abnormal heart rhythm}

Signs of heart failure, tachycardia or bradycardia – for treatment see heart failure section

• Obstructive {pericardial tamponade, tension pneumothorax}
• Raised jugular venous pulse, pulsus paradoxus
• Distributive {sepsis, anaphylaxis, neurogenic}
• May have hyperthermia or hypothermia, tachycardia, altered mental status

Important emergency assessment: Is there a pulse?

• If no pulse, start CPR
• Give Adrenaline immediately and every 4 minutes: 0.1 ml/kg of 1:10,000 IV/IO
• If able to assess the cardiac rhythm, a defibrillator is available, and staff are trained to us
  • Shockable rhythm identified (VF or pulseless VT)
  • DC shock 4 J/kg every 2 minutes
  • Continue CPR
  • Give Adrenaline every 4 minutes 0.1 ml/kg of 1:10,000 IV/IO
  • Give Amiodarone 5 mg/kg IV/IO after 3rd and 5th shock

If there is a pulse assess for signs of shock = a mismatch between circulatory supply and tissue demand

• Cold peripheries
• Capillary refill time >3 seconds
• Weak thready peripheral pulse

HYPOVOLEMIA (HYPOVOLEMIC SHOCK)

CLINICAL FEATURES

• It is most precipitated by fluid loss or blood loss
• Causes of fluid loss include vomiting, diarrhea, diuresis, poor PO intake
• Causes of blood loss include trauma, GI bleeds, PV bleeding

Management:

• IV fluid resuscitation is a priority
• Start with 20ml/kg of Sodium chloride 0.9% or Ringer's lactate as a bolus
• Repeat bolus if required
• Trauma or other bleeding patients should be given whole blood if blood pressure and heart rate not improved with IV fluids.
• Treat cause of fluid loss or blood loss

SEPSIS (SEPTIC SHOCK)

CLINICAL DESCRIPTION

It is most precipitated by infections such as pneumonia, meningitis, abscesses, peritonitis or septic miscarriages

Management:

• IV fluid resuscitation is a priority
• Start with 30ml/kg of Normal Saline or Ringers Lactate as a bolus unless patient has signs of heart failure
• Broad spectrum IV antibiotics (e.g. Ceftriaxone 2g IV q24h x 5/7 must be given as soon as possible)
• Control/treat the source of infection

Example: remove infected catheters, drain abscesses,

• If patient remains hypotensive repeat bolus of 500ml-1L may be required and Adrenaline infusion may be considered (discuss with senior)

ANAPHYLAXIS (ANAPHYLACTIC SHOCK)CLINICAL DESCRIPTION

It requires prompt treatment for laryngeal oedema, bronchospasm, and hypotension.

It is most precipitated by:

• Drugs {antibiotics, NSAIDs}
• Insect stings {especially wasps and bees}
• Blood products and blood transfusions
• Certain foods e.g., eggs, cow's milk, nuts

General Measures:

• Adrenaline IM is a priority
• Determine and remove cause

Management:

• Give Adrenaline 0.01 mg/kg IM anterior lateral thigh with max dose (0.5mg is max dose).
• Repeat as required (several times if necessary) every 10 minutes according to BP and pulse until improvement occurs
• Give Normal Saline 20 ml/kg by IV as a bolus
• Give Promethazine 25-50 mg by deep IM or, in emergencies, slow IV, as a solution containing 2.5 mg/ml in water for injection
• Promethazine should be repeated q8h. It is given after adrenaline and continued for 24-48 hours to prevent relapse.
• Steroids should also be given after initial treatment with adrenaline to prevent further deterioration

 Adults:

• Give Hydrocortisone 200 mg by slow IV push q6h for 24-48 hours
• When hydrocortisone not available Prednisolone may be used at 1mg/kg PO with max dose 60 mg q24h for 3 days
• Monitor pulse, BP, bronchospasm, and general response/condition every few minutes
• If there is continuing deterioration or no improvement the following may be necessary:
• Give nebulised Salbutamol as for asthma if bronchospasm persists {see Section on Respiratory Infection: Asthma}
• Ventilation and/or tracheotomy if laryngeal oedema severe

MANAGEMENT OF SHOCK IN CHILDREN

There are many causes of shock in children:

• Hypovolemic: gastroenteritis, hemorrhage, burns
• Distributive: sepsis, anaphylaxis
• Dissociative: severe anemia
• Cardiogenic: heart failure
• Obstructive: cardiac tamponade

Management of shock is dependent on the underlying cause:

Gastroenteritis 

• High flow oxygen
• Plan C using Ringer’s Lactate or 0.9% saline
  • < 12 months = 30 ml/kg over 1 hour
  • >12 months = 30 ml/kg over 30 minutes
  • Then reassess
  • If no improvement, repeat the 30 ml/kg
  • If improved continue with the 70ml/kg for 5hrs in <12 months and 2.5hrs in >12 months

Sepsis

• High flow oxygen
• 10 ml/kg over 1 hour, then reassess
• If no improvement, repeat up to a maximum of 40 ml/kg
• If still no improvement, consider blood, CPAP/ventilation, inotropic support
• Antibiotics as directed by the likely source of infection.

Anaemia

• Blood transfusion
• NEVER give a fluid bolus
• If no blood available, then give maintenance fluids

Trauma

• Apply pressure to any sources of catastrophic hemorrhage
  • Immediate management of internal hemorrhage
  • High flow oxygen
  • Vascular access: 2x large bore
  • Take blood samples
  • Tranexamic acid 15 mg/kg IV/IO q8h for 5days
  • Fluid resuscitation if shocked
  • Urgently request blood
  • 10 ml/kg 0.9% saline over 20 minutes, repeated up to a total of 40 ml/kg whilst awaiting blood
  • Keep warm
  • Analgesia
• Source of internal bleeding
  • Massive hemothorax
  • Chest-drain insertion
• Abdomen
  • eFAST scan, surgical review and intervention
• Pelvis
  • Application of a pelvic binder
• Long bone
  • Splinting of fracture
• Cardiac tamponade
  • Oxygen
  • Pericardiocentesis

If able assess the cardiac rhythm

• Ventricular tachycardia with a pulse; Treat underlying cause which is often due to hyperkalemia.
• Supraventricular tachycardia: treatment options include vagal maneuvers, adenosine, and synchronized DC shock.
• Adenosine
  • First dose: 100 micrograms/kg IV (150 micrograms/kg if < 1 year of age)
  • Second dose: 200 micrograms/kg IV     
  • Third dose: 300 micrograms/kg

Coma:

Assess the level of conscious using BCS, AVPU, GCS or children’s GCS

If reduced level of consciousness 

• Ensure airway patent: recovery position, consider airway adjuncts or need for intubation and ventilation
• Put on high-flow oxygen

Establish the cause by assessing for: 

• Signs of meningism: neck stiffness, Kernig’s sign, tone, photophobia, fontanelle
• Neurology: posture, focal signs, pupil size and reactivity
• Blood pressure
• Random blood sugar (RBS)
• Blood gas if available
• Urine dipstick

Treat underlying cause

Hypoglycemia

• Administer 10% dextrose (5ml/kg)

Malaria 

• Treat with IV/IM Artesunate
  • < 20 kg: 3.0 mg/kg at admission, then at 12 hours and 24 hours, then once per day
  • > 20 kg: 2.4 mg/kg at admission, then at 12 hours and 24 hours, then once per day 

Meningitis 

• Treat with IV antibiotics
  • Neonate: Benzylpenicillin 100,000 IU/kg q6h and Gentamicin 5 mg/kg q24h for 5-7 days
  • Children >1 month of age: Ceftriaxone 100 mg/kg q24h for 5-7 days

Encephalitis 

• Treat with IV Acyclovir
  • 3 month – 12 years: 500 mg/m2 q8h for 14 days
  • 12-18 years: 10 mg/kg q8h for 14 days

Organophosphate poisoning

• Activated charcoal if available and ingestion occurred < 4 hours ago
• Neonate – 12 years 1 g/kg PO (max. 50 g)
• 12 – 18 years 50g

If respiratory compromise give oxygen and treat with Atropine 20 micrograms/kg IM /IV. Repeat every 15 minutes until the chest is dry. 

May need referral to Pediatric ICU

Diabetic ketoacidosis

• ABCCCD: give oxygen to patients with circulatory impairment or shock.
• Fluid replacement
• If in shock give 10 ml/kg 0.9% saline over 1 hour
• Fluid requirement = maintenance (for 48 hours) + deficit
• Deficit (ml) = % dehydration x weight (kg) x 10
• Do not calculate above a 7.5% deficit
• Correct over 48 hours
• Do not include bolus fluids in this calculation unless a total of 20 ml/kg or more has been given
• Insulin therapy
  • Should be short acting, soluble, ‘clear’
  • Ideally administered via a syringe pump
  • Start IV at 0.05 units/kg/hour
  • Once RBS <15 mmol/l change fluid to 0.9% saline and 5% dextrose. Do not reduce the rate of insulin
• Potassium replacement
• Needed for every child in DKA if they are passing urine
• Add Potassium Chloride to IV fluids (20 mmol to each 500 ml bag)

Ongoing management

Monitor blood sugar levels hourly

Head injury 

• Aim to prevent secondary brain injury
• High-flow oxygen
• Maintain normovolaemia
• Tranexamic acid 15 mg/kg IV/IO
• Maintain normoglycemia
• Tilt bed to 30°
• If evidence of raised ICP give either 3% hypertonic saline (3-5 ml/kg) or mannitol (250-500 mg/kg).
• Manage convulsions
• Maintain normothermia

Convulsions:

• Emergency treatment of seizures
• ABCCCD approach:
• Ensure the airway is open
• Administer oxygen
• Manage circulatory impairment
• Treat hypoglycemia with 5 ml/kg of 10% dextrose
• Convulsions lasting longer than 5 minutes require anticonvulsants

Child > 2 weeks of age

• Paraldehyde  IM 0.2 ml/kg OR PR 0.4 ml/kg
• Still fitting after 10 minutes repeat Paraldehyde IM 0.2 ml/kg OR PR 0.4 ml/kg
• Still fitting after 10 minutes Diazepam IV 0.25 mg/kg OR PR 0.5 mg/kg

(Note this will be given first if no paraldehyde available)

• Still fitting after 10 minutes Diazepam IV 0.25 mg/kg OR PR 0.5 mg/kg
• Still fitting after 10 minutes Phenobarbital IM 20 mg/kg
• Still fitting after 20 minutes repeat Phenobarbital IM 20 mg/kg
• Still fitting after 20 minutes Phenytoin IV 18 mg/kg over 20 minutes
• Still fitting after 20 minutes consider Levetiracetam IV/NGT 30 mg/kg OR Ketamine IV 1-2 mg/kg

Child ≤ 2 weeks of age

• Do not give Diazepam in neonates <2 weeks of age
• Phenobarbitone IM 20 mg/kg
• Still fitting after 10 minutes Phenobarbitone IM 20 mg/kg
• Still fitting after 10 minutes Paraldehyde IM 0.2 ml/kg OR PR 0.4 ml/kg

Note:  Paraldehyde MUST NOT be given IV, Diazepam MUST NOT be given IM

Once the convulsion has been managed, identify and treat underlying cause of the seizure.

Common causes of convulsions in children include:

• Fever, Malaria, hypoglycemia, intracranial infections, hypoxia, head injury, stroke, epilepsy, poisoning, hypertensive encephalopathy.

Common causes of convulsions in neonates include:

• Hypoglycemia, birth asphyxia, intracranial infection, intracranial hemorrhage, fecal ischaemic injury.

Dehydration:

Assess for signs of severe dehydration: sunken eyes, reduced skin turgor and lethargy. 

Treat with Plan C using Ringer’s Lactate or 0.9% saline. 

Plan C: for severe dehydration +/- shock
< 12 months •        30 ml/kg over 1 hour •        Reassess  •        If no improvement: repeat 30 ml /kg •        If improved: 70 ml/kg over 5 hours	>12 months •        30 ml/kg over 30 minutes  •        Reassess  •        If no improvement: repeat 30 ml /kg •        If improved: 70 ml/kg over 2.5 hours