Paediatric Shock

Question 1

What is shock?

Answer 1

Lack of perfusion to the peripheries leading to a lack of adequate cellular metabolism, leading to the accumulation of cellular waste

Question 2

What features are suggestive of septic shock?

Answer 2

• Localising symptoms
• Fulminant DIC with purpuric rash
• NOT FEVER

Question 3

Are patients with septic shock febrile?

Answer 3

NO. Fever is not the defining feature of septic shock. May be cold, euthermic or febrile.

Question 4

What causes cold septic shock?

Answer 4

• 1. Cardiac dysfunction due to lactic academy from septic process
• 2. Children cannot increase SV, only inc HR to inc CO

Question 5

What is warm septic shock? Features?

Answer 5

Vasodilatory:

• fever
• bounding pulse
• wide pulse pressure

Question 6

Young or older children more likely to present with warm septic shock?

Answer 6

The older the child, the more likely warm shock.

Question 7

Mx septic shock?

Answer 7

Resuscitation Pod.

• ABCs
• Prompt ABx (within 30minutes of arrival).
• Fluid resuscitation
• Consider inotropes
• Fluid, inotrope resistant = ECMO

Question 8

Components of C in primary survey of septic shock?

Answer 8

• 2x IV access attempts; prepare for IO / umbilical

- Bloods: B/C, BSL, VBG (for lactate)

Question 9

Organisms to cover and ABx for neonates with septic shock?

Answer 9

Neonates (GBS, E coli, Listeria):

• empirical: benzylpenicillin, cefotaxime.
• If UTI: add gentamicin.

Question 10

Older children: ABx and organisms in septic shock?

Answer 10

Older children (Staph, strep, meningicoccal ):

• flucloxacillin
• 3rd generation ceph (cefotaxime or ceftriaxone) for BBB access

Question 11

Immunocompromised / neutropenic patients: ABx and organisms to cover in septic shock?

Answer 11

• Tazocin: cover pseudomonas

- Vancomycin (MRSA)

Question 12

Approach to fluid resuscitation in paediatric septic shock?

Answer 12

20ml/kg NS - 40ml/kg (in older children), then stand at the bed to watch the HR, peripheral perfusion
• With rapid assessment of another bolus, continue to bolus them
• Start drawing up inotropes if starting 40ml/kg
Neonatal be careful: as sepsis can masqeurade cardiogenic shock (CHD)

Question 13

Why do septic shock patients respond poorly to fluid resuscitation?

Answer 13

Fluids resuscitation - do not respond as well to this because they have leaky vessels

Question 14

Why is warm septic shock v cold septic shock important to determine when giving inotropes?

Answer 14

• Warm shock, the problem is vasodilation: therefore give NA to vasoconstrict
• Cold shock: adrenaline to increase pump

Question 15

Why do neonates often get started on dobutamine?

Answer 15

Shock is more commonly cariogenic and cold septic shock.

Question 16

Can NA and adrenaline be given peripherally?

Answer 16

Yes but diluted. Tissue necrosis if given undiluted.

Question 17

Post resuscitation care after septic shock?

Answer 17

• Monitor BSL
• Monitor BP and maintain
• VBG: monitor CO2, electrolytes, pH
• ABG is important to look at PO2 therefore take when intubated and lactate

Question 18

Which CHD lesions generally present in shock?

Answer 18

The PDA dependent lesions:

• Critical AS
• Coarctation
• Transposition

Question 19

How do neonates with cardiogenic shock preesent?

Answer 19

• Floppy
• Cold
• Mottled
• Poor feeding
  (Looks similar to septic neonate).

+/-:

• Murmur
• Four limb BP
• Decreased femoral pulses

Question 20

What are the causes of cardiogenic shock in older children?

Answer 20

• Myocarditis
• AMI
• Ongoing SVT

Question 21

How long can umbilical artery / vein access be obtained?

Answer 21

Up to 4 days

Question 22

Mx cardiogenic shock?

Answer 22

• AB
• C: access
• Cautious 10mL/kg NS
• PGE
• Still ABx as hard to differentiate
• Dobutamine in most

Question 23

What is the biggest danger of PGE?

Answer 23

Apnoea. Must always prepare for:

• intubation
• transfer

Question 24

Causes of hypovolaemic shock?

Answer 24

Fluid:
- Gastro
- DKA
Blood:
- Haemorrhage (trauma)
- Bleeding from PUD or GIT lesion

Question 25

Sites of occult blood loss?

Answer 25

- Chest - Pelvis - Abdo - Long bones - Head (in neonates)

Question 26

Approach to hypovolemic shock?

Answer 26

``` AB (with O2) C: - Gain access - IVABx if ?sepsis - Bloods: +UEC and BSL (?DKA) -Fluid 20mL/kg: most resolve after first bolus. Keep bolus until out of shock and into dehydration (if correct DKA into normovolemia will get cerebral oedema) ```

Question 27

Aim of fluid bolus in hypovolemic shock? Why?

Answer 27

Keep bolusing until out of shock and into dehydration (if correct DKA into normovolemia will get cerebral oedema)

Question 28

What are the signs of cardiac tamponade?

Answer 28

Beck's Triad: - Distended neck veins - Poor pulses - Muffled heart sounds

Question 29

Causes of obstructive shock?

Answer 29

Usually traumatic causes of: - Tension pneumo - Cardiac tamponade - PE (if adolescent on OCP)

Question 30

Mx of cardiac tamponade?

Answer 30

* ABCD * Pericardial window * If arrest, then emergency pericardiocentesis * Echo to diagnose

Question 31

What is distributive shock?

Answer 31

i. e. anaphylaxis: - Respiratory or CV features PLUS - Mucocutaneous or GI effects