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Case Report

Approach in shock in pediatrics … when minutes matter...!

Said Eldeib1,*, Jayaraj Damodaran1, Ali Wahba2, Ayman Khayal3, Mohamed Atif Attia3, Ahmed Elbarmeshty4, Abedallattif khalloof5 and Hany Mousa5

1Department of pediatrics, ADSCC/Yas clinic Hospital, UAE
2Department of pediatrics, SSMC hospital, AD, UAE
3Department of pediatrics, SKMC hospital, AD, UAE
4Department of pediatrics, Munich medical &rehabilitation center, Al Ain UAE
5Department of pediatrics, Mediclinc Al Jawhraa Hospital Al Ain, UAE

Received Date: 14/03/2023; Published Date: 31/05/2023

*Corresponding author: Dr. Said Eldeib, Department of pediatrics ADSCC/ Yas clinic Hospital, Abu Dhabi, UAE

DOI: 10.46998/IJCMCR.2023.26.000650

Abstract

Early recognition of shock in children is crucial for optimal outcome but is not always obvious. Clinical experience, gut feeling, and careful and repeated interpretation of the vital parameters are essential to recognize and effectively treat the various forms of shock.

The clinical signs and symptoms of shock in newborns and children are often more subtle compared to adults. Recurring, avoidable factors for optimal outcome include failure of health care workers to recognize shock at the time of presentation. Children are able to compensate a shock state for longer periods than adults resulting in a sudden, sometimes irreversible, cardiopulmonary collapse. Different forms of shock, their therapy, and frequent errors are depicted and illustrated with practical examples.

Inappropriate volume for fluid resuscitation (usually too little for children with sepsis or hypovolemic shock, but possibly too much for those with cardiogenic shock   also Failure to reconsider possible causes of shock for children who are getting worse or not improving, Failure to recognize and treat obstructive shock.

The management of children with shock is challenging. Some pitfalls include, Failure to recognize nonspecific signs of compensated shock (ie, unexplained tachycardia, abnormal mental status, or poor skin perfusion) could be due to Inadequate monitoring of response to treatment

Keywords: Shock in children; Cardiac failure; Volume expanders; Anaphylaxis; Arrythmia

Introduction

Shock: is a condition characterized by a significant reduction in tissue perfusion, resulting in decreased tissue oxygen delivery [1].

  • Compensated shock: The body compensate for diminished perfusion and SBP is maintained within the normal range by tachycardia and peripheral vasoconstriction (cool skin and decreased peripheral pulses) [2].
  • Hypotensive shock: Compensatory mechanisms are overwhelmed. Heart rate is markedly elevated, and hypotension develops.
  • Irreversible shock: Bradycardia and blood pressure becomes very low, irreversible organ damage and death [2].

Classification of shock

  • Hypovolemic shock
  • Distributive shock
  • Septic shock
  • Anaphylaxis
  • Neurogenic shock
  • Cardiogenic shock
  • Obstructive shock [3]

The Pathophysiology of Shock

Shock is characterized by a relative imbalance between the delivery of oxygen and metabolic substrates and the metabolic demands of the cells and tissues of the body. While the shock state most commonly occurs in the setting of decreased oxygen delivery, it is certainly feasible that excessive metabolic demands could produce a similar pathologic state. However, the body’s compensatory mechanisms are able to adjust to meet even incredibly high metabolic demand, so that a state of shock will usually only occur in the setting of decreased oxygen and substrate delivery [4].

Under resting conditions, with normal distribution of cardiac output, oxygen delivery (DO2) is more than adequate to meet the total oxygen requirements of the tissues needed to maintain aerobic metabolism, referred to as oxygen and VO2 result in a mathematical coupling of measurement errors in the shared variables resulting in false correlation between oxygen delivery and consumption. In order to avoid potential mathematical coupling, oxygen consumption and delivery should be determined independent of each other.

Studies in which VO2 was directly measured (rather than calculated) have largely disproved this pathologic supply dependency hypothesis. Regardless, during the shock state, the body’s compensatory mechanisms, as well as our therapeutic efforts, are largely directed at optimizing the balance between oxygen delivery and consumption [5].

Common Features:

    Early

  • Tachycardia
  • Compromised organ perfusion
  • Skin: cool, clammy, pale, or mottled
  • Brain: drowsy, lethargy.
  • Kidneys: Oliguria.
  • Lactic acidosis

Late: hypotension [6]

  Rapid Assessment:

  Pediatric Assessment Triangle (PAT)

Appearance:

  • (Poor tone, unfocused gaze, weak cry, decreased responsiveness to caretakers or painful procedures) may be indicators of decreased cerebral perfusion. (7)

Breathing:

  • Depressed respiration due to depressed mental status.
  • Respiratory distress:
  • Obstructive shock (Tension pneumothorax, Cardiac tamponade, and Massive pulmonary embolism)
  • Cardiogenic shock: Ductal-dependent congenital heart disease [8-10].

Circulation:

  • Poor perfusion
  • Skin temperature, mottled or cool.
  • Capillary refill > 2 seconds suggests shock.
  • Flash capillary refill (<1 second) may be present.
  • Heart rate: Tachycardia
  • Decreased intensity of distal pulses in comparison to central pulses
  • Bounding pulses may be present. [11-13]

Physical examination

**Vital signs: Respiratory rate, Heart rate, Temperature, Blood pressure

    Chest

  • Stridor, wheezing, or abnormal breath sounds: anaphylaxis.
  • crackles may have a pneumonia (septic shock) or heart failure (cardiogenic shock)
  • asymmetric breath sounds: tension pneumothorax [14-17]
  •  

      CVS

  • Distended neck veins in heart failure, or cardiac tamponade or tension pneumo- or hemothorax.
  • Murmurs or a gallop rhythm: heart failure and cardiogenic shock.
  • Muffled heart tones: cardiac tamponade.

Pulse differential: coarctation of the aorta [18,19]

      Abdomen

  • Hepatomegaly: heart failure, cardiogenic shock.
  • Abnormal skin findings:
  • Urticaria or facial edema suggests anaphylaxis.
  • Purpura can be seen with septic shock.
  • Bruises and/or abrasions may be noted with trauma [20,21].

    Approach to the classification of undifferentiated shock in children [22]

Sepsis definitions:

  • Sepsis: SIRS in the presence of suspected or proven infection [23].
  • Systemic inflammatory response syndrome (SIRS):

The presence of at least 2 of the following 4 criteria, one of which must be abnormal temperature or leucocyte count:

  1. Core temperature of >38.5°C or <36°C.
  2. Leucocyte count elevated or depressed for age
  3. Tachycardia, or bradycardia
  4. Mean respiratory rate increased or decreased from normal [24-27]
  • Septic shock: Sepsis and cardiovascular organ dysfunction [28]

    Septic shock: initial resuscitation (first hour)

  • In the first hour of resuscitation, the goals are to maintain: Airway, breathing and Circulation [29]
  • Obtain vascular access (IV or intraosseous [IO]) within 5 minutes
  • Start appropriate fluid resuscitation within 30 minutes
  • Begin broad-spectrum antibiotics within 60 minutes
  • For patients with fluid-refractory shock, initiate peripheral or central inotropic infusion within 60 minutes [30-33]

    Airway and breathing:

  • 100 percent oxygen, titrated to avoid SpO2 >97 percent.
  • Rapid sequence intubation (RSI) if needed to protect the airway, [34,35]

     Common used inotropes:

1- Epinephrine (adrenaline): (0.05 to 0.1 mcg/kg/minute, up to 1.5 mcg/kg/minute)

  • The most common used inotrope, used in septic shock, anaphylactic shock, asystolic arrest.
  • S/E: Constriction of renal and splanchnic vesssels, Tachyarrhythmias, Hyperglycaemia [36]

2- Norepinephrine (noradrenaline):(0.01 - 0.1 mcg/kg/minute) up to 1 – 2 mcg/kg/min

  • Used alone in septic shock or with epinephrine in cases of resistant shock requiring high dose epinephrine
  • S/E: Bradycardia, reducing tissue perfusion [37]

3- Dopamine: 3–20mcg/kg/min

  • Used n septic shock if epinephrine and epinephrine not available
  • S/E: tachyarrhythmias, and pulmonary vasoconstriction
  • It can give prepherally in small dose if central line not available [37-39]

   Less commonly used inotropes

4-Dobutamine: 5–20mcg/kg/min

  • Used in cardiogenic shock
  • S/E: Tachyarrhythmia, hypotension due to peripheral vasodilatation (39)

5-Milrinone: 0.25–1mcg/kg/min

  • Used in cardiogenic shock or low cardiac output state following cardiopulmonary bypass
  • S/E: Arrhythmias, Hypotension, thrombocytopenia [40].

6-Vasopressin: 0.02–0.09U/kg/h

  • Used in in children with septic shock who require high-dose catecholamines
  • Side effects: splanchnic and peripheral ischaemia due to severe vasoconstriction [41].

      laboratory studies for children with sepsis and septic shock:

  1. Rapid blood glucose
  2. Arterial or venous blood gas
  3. Complete blood count with differential
  4. Blood lactate
  5. Blood urea nitrogen and serum creatinine
  6. serum electrolytes
  7. LFT
  8. PT, INR and APTT
  9. Fibrinogen and D-dimer
  10. Blood culture urine culture csf culture
  11. Other cultures as indicated by clinical findings
  12. Inflammatory biomarkers (eg, C-reactive protein, procalcitonin) [42-44]

     Goal-targeted therapy for septic shock [45]

Discussion

Therapeutic endpoints of septic shock:

  1. Quality of central and peripheral pulses (strong, distal pulses equal to central pulses)
  2. Skin perfusion (warm, with capillary refill <2 seconds)
  3. Mental status (normal mental status) [46]
  4. Urine output (≥1 mL/kg/hour)
  5. Blood pressure (systolic pressure at least fifth percentile for age): 60 mmHg <1 month of age, 70 mmHg + [2 x age in years] in children 1 month to 10 years of age, 90 mmHg in children 10 years of age or older) [47]
  6. Normal serum lactate (eg, <2 mmol/L)

1. Emerging Issues

Multisystem inflammatory syndrome in children (MIS-C) was defined by the Centers for Disease Control and Prevention in 2020 as a patient younger than 21 years of age with fever for more than 24 hours, laboratory evidence of inflammation and multisystem organ involvement without alternative plausible diagnosis, and a recent or current SARS-CoV-2 infection.84,85 Consider the diagnosis in patients with a Kawasaki-like illness, toxic shock syndrome, or macrophage activation syndrome. Hypotension was present in 80% of MIS-C cases reported as of October 2020, and 60% to 80% of patients required ICU admission due to shock requiring vasopressor support [47].

Obtain a C-reactive protein, erythrocyte sedimentation rate, D-dimer, fibrinogen, procalcitonin, lactate dehydrogenase, and SARS-Cov-2 antibody or antigen screening as part of the workup.

Treatment includes immune-suppression under the guidance of specialists, including cardiology, infectious disease, and rheumatology. Reported complications are coronary artery aneurysms in 10% to 20% of cases, coagulopathy abnormalities, and a 1% to 2% mortality.85 ECLS has been used for a miniscule number of COVID-19 or MIS-C patients with varying levels of success, but there are insufficient data to determine its efficacy [48].

2. Disposition

Almost all pediatric shock patients require admission, usually to the PICU. Septic pediatric patients should be transferred to a tertiary care center with pediatric intensivists.

In the case of resolved anaphylactic shock, otherwise healthy patients who remain symptom free can be discharged after observation, although a specific disposition time has not been clearly established. One hour of observation incurs a 5% chance of biphasic reaction out-of-hospital, while six hours of observation may reduce that risk to 3%.86 Disposition also should consider the child’s family, transportation needs, and the ability for the family to accommodate specific pediatric needs [48].

While free-standing and critical access EDs have provided easier access to care, pediatric patient transfers have been increasing over time.1 To that end, having specialized pediatric transport systems in place has been shown to improve safety, decrease unplanned adverse events, and lower mortality.87-89 Ensuring that the transport team is composed of a physician, well-experienced nurses, paramedics, and possibly respiratory therapists, and that transport vehicles are equipped with all essential equipment is vital. It also is important to understand that during transport, patients are at increased risk for hypothermia and hypoglycemia; thus, having IV access is imperative [49].

        Management of hypovolemic shock:

Goal:

Restore circulating volume and tissue perfusion, correct the cause

  • Assess airway, administer oxygen and Establish IV access
  • Fluid bolus of 20ml/kg isotonic fluid given over 5-10 minutes, continue fluid boluses until perfusion improves or hepatomegaly develops [49]
  • In case of shock refractory to fluids, should be evaluated for ongoing blood loss or other causes of shock.
  • Correct hypoglycemia and electrolytes disturbance if present [49]
  • Vasoactive medications have no place in the treatment of isolated hypovolemic shock [50]

       Management of cardiogenic shock:

  • Assess airway, administer oxygen/mechanical ventilation, IV access
  • A smaller isotonic crystalloid fluid bolus of 5 to 10 mL/kg, over 10 to 20 minutes
  • Treatment with dobutamine or phosphodiesterase enzyme inhibitors can improve myocardial contractility and reduce systemic vascular resistance (afterload)
  • Cardiac arrhythmias (eg, supraventricular or ventricular tachycardia) should be addressed prior to fluid resuscitation [51]

Management of anaphylactic shock:

  • The first and most important therapy in anaphylaxis is epinephrine. There are NO absolute contraindications to epinephrine in the setting of anaphylaxis.
  • Airway: Immediate intubation if evidence of impending airway obstruction from angioedema. Intubation can be difficult and should be performed by the most experienced clinician available or by anesthesia doctor, give 100% oxygen.
  • IM epinephrine (1 mg/mL preparation = 1:1000 solution): Epinephrine 0.01 mL/kg should be injected intramuscularly in the mid-outer thigh. injection can be repeated in 5 to 15 minutes (or more frequently). If no response after three injections prepares IV epinephrine for infusion.
  • Place patient in recumbent position, if tolerated, and elevate lower extremities.
  • Normal saline rapid bolus: 20 mL/kg.
  • Albuterol: For bronchospasm resistant to IM epinephrine, give albuterol 0.15 mg/kg (minimum dose: 2.5 mg) in 3 mL saline inhaled via nebulizer. Repeat, as needed.
  • H1 antihistamine: Consider giving diphenhydramine 1 mg/kg (max 40 mg) IV.
  • Glucocorticoid: Consider giving methylprednisolone 1 mg/kg (max 125 mg) IV [52].

       Management of neurogenic shock:

  • Intravenous fluids, and pharmacologic vasopressors as needed.
  • Bradycardia caused by cervical spinal cord or high thoracic spinal cord disruption may require external pacing or administration of atropine.
  • Correct hypothermia,
  • Observe and prevent DVT (due to peripheral pooling of blood) [53]

      Management of obstructive shock:

  • Assess airway, administer oxygen/mechanical ventilation, IV access [53]
  • Causes of obstructive shock (eg, tension pneumothorax, cardiac tamponade, hemothorax, pulmonary embolism, or ductal-dependent congenital heart defects) require specific interventions to relieve the obstruction to blood flow [53].

Conclusion

The management of children with shock is challenging. Some pitfalls include:

  • If peripheral line is difficult, don’t waste time in multiple trials, don’t try for central line insertion, just insert intraosseous  access.
  • Failure to recognize nonspecific signs of compensated shock (ie, unexplained tachycardia, abnormal mental status, or poor skin perfusion)
  • Inadequate monitoring of response to treatment
  • Inappropriate volume for fluid resuscitation (usually too little for children with sepsis or hypovolemic shock, but possibly too much for those with cardiogenic shock)
  • Failure to reconsider possible causes of shock for children who are getting worse or not improving.

Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Funding: This research received no external funding.
Conflicts of Interest: All other authors report no conflicts of interest. Data Availability Data described in the   manuscript, code book, and analytic code will be made available upon request pending application and approval.

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