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Circulatory system failure to supply oxygen and nutrients to meet cellular metabolic demands

Circulatory system failure to supply

oxygen and nutrients to meet cellular

metabolic demands

 Blood Pressure BP = CO x SVR  Cardiac Output CO = SV X HR
  • Blood Pressure

BP = CO x SVR

  • Cardiac Output

CO = SV X HR

  • Vascular Tone (SVR)

    • Regulated by several mechanisms

Blood Pr essur e Cardiac Output Strok e Volume Heart Rate Systemic Vascular Re sis tance

Blood

Pr essur e

Blood Pr essur e Cardiac Output Strok e Volume Heart Rate Systemic Vascular Re sis tance

Cardiac Output

Blood Pr essur e Cardiac Output Strok e Volume Heart Rate Systemic Vascular Re sis tance

Strok e Volume

Heart Rate

Systemic Vascular

Re sis tance

Myocar dial

Contractility

Pr eload

Afterload

Textbook of Pediatric Advanced Life Support, 1988
Textbook of Pediatric Advanced Life Support, 1988
 Cardiac Output  Clinical Assessment  peripheral perfusion, temperature, capillary refill, urine output, mentation, acid-base
  • Cardiac Output

    • Clinical Assessment

      • peripheral perfusion, temperature, capillary refill, urine output, mentation, acid-base status

    • CO = HR x SV

      • HR responds the quickest

      • SV is a function of three variables

        • preload, afterload, and myocardial contractility

      • A noncompliant heart cannot increase SV

 Preload (LVEDV)  Reflects patient’s volume status  CVP or PCWP  Starling curve 
  • Preload (LVEDV)

    • Reflects patient’s volume status

    • CVP or PCWP

    • Starling curve

  • Afterload

    • The resistance to ventricular ejection

    • Two variables:

      • vascular tone and transmural pressure

  • Myocardial Contractility (“squeeze”)

    • Many factors including coronary perfusion, baseline myocardial function, use of cardiotonic medications

  • • COMPENSATED – blood flow is normal or increased and may be maldistributed; vital organ function

    COMPENSATED

    blood flow is normal or increased and may be maldistributed; vital organ function is maintained

    UNCOMPENSATED

    microvascular perfusion is compromised; significant reductions in effective circulating volume

    IRREVERSIBLE

    inadequate perfusion of vital organs; irreparable damage; death cannot be prevented

     Hypovolemic or Hemorrhagic  Cardiogenic  Obstructive  Distributive
    • Hypovolemic or Hemorrhagic

    • Cardiogenic

    • Obstructive

    • Distributive

    Type Preload Afterload Contractility Cardiogenic    Hypovolemic   No change Distributive  

    Type

    Preload

    Afterload

    Contractility

    Cardiogenic

    Hypovolemic

    No change

    Distributive

    Septic

    early

    late

     Regardless of the cause: ABC’s  First assess airway patency, ventilation, then circulatory system 
    • Regardless of the cause: ABC’s

      • First assess airway patency, ventilation, then circulatory system

    • Respiratory Performance

      • Respiratory rate and pattern, work of breathing, oxygenation (color), level of alertness

    • Circulation

      • Heart rate, BP, perfusion, and pulses, liver size

      • CVP monitoring may be helpful

     Early Signs of Shock  sinus tachycardia  delayed capillary refill  fussy, irritable 
    • Early Signs of Shock

      • sinus tachycardia

      • delayed capillary refill

      • fussy, irritable

  • Late Signs of Shock

    • bradycardia

    • altered mental status (lethargy, coma)

    • hypotonia, decreased DTR’s

    • Cheyne-Stokes breathing

    • hypotension is a very late sign

    • Lower limit of SBP = 70 + (2 x age in years)

  •  Heart Rate  Too high: 180 bpm for infants, 160 bpm for children >1year old
    • Heart Rate

      • Too high: 180 bpm for infants, 160 bpm for children >1year old

    • Blood Pressure

      • Lower limit of SBP = 70 +

    (2 x age in years)

    • Peripheral Pulses

      • Present/Absent

      • Strength (diminished, normal, bounding)

        • Skin Perfusion

          • Capillary refill time

          • Temperature

          • Color

          • Mottling

  • CNS Perfusion

    • Recognition of parents

    • Reaction to pain

    • Muscle tone

    • Pupil size

  • Renal Perfusion

    • UOP >1cc/kg/hr

  • Airway management  Always provide supplemental oxygen  Endotracheal intubation and controlled ventilation is suggested if

    Airway management

    • Always provide supplemental oxygen

    • Endotracheal intubation and controlled ventilation is suggested if respiratory failure or airway compromise is likely

      • elective is safer and less difficult

      • decrease negative intrathoracic pressure

      • improved oxygenation and O 2 delivery and decreased O 2 consumption

      • can hyperventilate if necessary

    Circulation  Based on presumed etiology  Rapid restoration of intravascular volume  PIV-if unstable you

    Circulation

    • Based on presumed etiology

    • Rapid restoration of intravascular volume

      • PIV-if unstable you have 60-90 seconds

      • I.O. if less than 4-6 years old

      • Central venous catheter

      • Use isotonic fluid: NS, LR, or 5% albumin

      • PRBC’s to replace blood loss or if still unstable after 60cc/kg of crystalloid

        • anemia is poorly tolerated in the stressed, hypoxic, hemodynamically unstable patient

     Dopamine  1-5 mcg/kg/min: dopaminergic  5-15 mcg/kg/min: more beta-1  10-20 mcg/kg/min: more alpha-1
    • Dopamine

      • 1-5 mcg/kg/min: dopaminergic

      • 5-15 mcg/kg/min: more beta-1

      • 10-20 mcg/kg/min: more alpha-1

      • may be useful in distributive shock

  • Dobutamine

    • 2.5-15 mcg/kg/min: mostly beta-1, some beta-2

    • may be useful in cardiogenic shock

  • Epinephrine

    • 0.05-0.1 mcg/kg/min: mostly beta-1, some beta-2

    • > 0.1 to 0.2 mcg/kg/min: alpha-1

  •  Norepinephrine  0.05-0.2mcg/kg/min: only alpha and beta-1  Use up to 1mcg/kg/min  Milrinone 
    • Norepinephrine

      • 0.05-0.2mcg/kg/min: only alpha and beta-1

      • Use up to 1mcg/kg/min

  • Milrinone

    • 50mcg/kg load then 0.375-0.75mcg/kg/min: phosphodiesterase inhibitor; results in increased inotropy and peripheral vasodilation (greater effect on pulmonary vasculature)

  • Phenylephrine

    • 0.1-0.5mcg/kg/min: pure alpha

  •  # 1 cause of death in children worldwide  Causes  Water Loss (diarrhea, vomiting
    • # 1 cause of death in children worldwide

    • Causes

      • Water Loss (diarrhea, vomiting with poor PO intake, diabetes, major burns)

      • Blood Loss (obvious trauma; occult bleeding from pelvic fractures, blunt abdominal trauma, “shaken baby”)

  • Low preload leads to decreased SV and decreased CO.

  • Compensation occurs with increased HR and SVR

  •  Mainstay of therapy is fluid  Goals  Restore intravascular volume  Correct metabolic acidosis
    • Mainstay of therapy is fluid

    • Goals

      • Restore intravascular volume

      • Correct metabolic acidosis

      • Treat the cause

  • Degree of dehydration often underestimated

    • Reassess perfusion, urine output, vital signs ...

  • Isotonic crystalloid is always a good choice

    • 20 to 50 cc/kg rapidly if cardiac function is normal

    • NS can cause a hyperchloremic acidosis

  • Solution Na+ Cl- K+ Ca++ Mg++ Buffer NS 154 154 0 0 0 None LR 130

    Solution

    Na+

    Cl-

    K+

    Ca++

    Mg++

    Buffer

    NS

    154

    154

    0

    0

    0

    None

    LR

    130

    109

    4

    3

    0

    Lactate

    Plasmalyte

    140

    98

    5

    0

    3

    Acetate & Gluconate

    • Inotropic and vasoactive drugs are not a substitute for fluid, however ...

      • Can have various combinations of hypovolemic and septic and cardiogenic shock

      • May need to treat poor vascular tone and/or poor cardiac function

     Treatment is PRBCs or whole blood  Treat the cause if able (stop the bleeding)
    • Treatment is PRBCs or whole blood

      • Treat the cause if able (stop the bleeding)

      • Transfuse if significant blood loss is known or if patient unstable after 60cc/kg crystalloid

        • In an emergency can give group O PRBCs before cross matching is complete or type specific non-cross- matched blood products

     Low CO and high systemic vascular resistance  Result of primary cardiac dysfunction:  A
    • Low CO and high systemic vascular resistance

    • Result of primary cardiac dysfunction:

      • A compensatory increase in SVR occurs to maintain vital organ function

      • Subsequent increase in LV afterload, LV work, and cardiac oxygen consumption

      • CO decreases and ultimately results in volume retention, pulmonary edema, and RV failure

     Congenital heart disease  Arrhythmias  Ischemic heart disease  Myocarditis  Myocardial injury 
    • Congenital heart disease

    • Arrhythmias

    • Ischemic heart disease

    • Myocarditis

    • Myocardial injury

    • Acute and chronic drug toxicity

    • Late septic shock

    • Infiltrative diseases

      • mucopolysaccharidoses

      • glycogen storage diseases

  • Thyrotoxicosis

  • Pheochromocytoma

  •  Initial clinical presentation can be identical to hypovolemic shock  Initial therapy is a fluid
    • Initial clinical presentation can be identical to hypovolemic shock

    • Initial therapy is a fluid challenge

    • If no improvement or if worsens after giving volume, suspect cardiogenic shock

    • Usually need invasive monitoring, further evaluation, pharmacologic therapy

    • Balancing fluid therapy and inotropic support can be very difficult.

      • Call an intensivist and/or a cardiologist

     Low CO secondary to a physical obstruction to flow  Compensatory increased SVR  Causes:
    • Low CO secondary to a physical obstruction to flow

    • Compensatory increased SVR

    • Causes:

      • Pericardial tamponade

      • Tension pneumothorax

      • Critical coarctation of the aorta

      • Aortic stenosis

      • Hypoplastic left heart syndrome

     Initial clinical presentation can be identical to hypovolemic shock  Initial therapy is a fluid
    • Initial clinical presentation can be identical to hypovolemic shock

    • Initial therapy is a fluid challenge

    • Treat the cause

      • pericardial drain, chest tube, surgical intervention

      • if the patient is a neonate with a ductal dependent lesion then give PGE

  • Further evaluation, invasive monitoring, pharmacologic therapy, appropriate consults

  •  High CO and low SVR (opposite of hypovolemic, cardiogenic, and obstructive)  Maldistribution of blood
    • High CO and low SVR (opposite of hypovolemic, cardiogenic, and obstructive)

    • Maldistribution of blood flow causing inadequate tissue perfusion

    • Due to release of endotoxin, vasoactive substances, complement cascade activation, and microcirculation thrombosis

    • Early septic shock is the most common form

     Goal is to maintain intravascular volume and minimize increases in interstitial fluid (the primary problem
    • Goal is to maintain intravascular volume and minimize increases in interstitial fluid (the primary problem is a decrease in SVR)

      • Use crystalloid initially

      • Additional fluid therapy should be based on lab studies

      • Can give up to 40cc/kg without monitoring CVP

      • Vasoactive/Cardiotonic agents often necessary

      • Treat the cause (i.e

    ..

    antimicrobial therapy)

     Anaphylaxis  Anaphylactoid reactions  Spinal cord injury/spinal shock  Head injury  Early sepsis
    • Anaphylaxis

    • Anaphylactoid reactions

    • Spinal cord injury/spinal shock

    • Head injury

    • Early sepsis

    • Drug intoxication

      • Barbiturates, Phenothiazines, Antihypertensives

     Metabolic acidosis develops secondary to tissue hypoperfusion  Profound acidosis depresses myocardial contractility and impairs
    • Metabolic acidosis develops secondary to tissue hypoperfusion

    • Profound acidosis depresses myocardial contractility and impairs the effectiveness of catecholamines

    • Tx: fluid administration and controlled ventilation

    • Buffer administration

      • Sodium Bicarbonate 1-2meq/kg or can calculate a 1/2 correction = 0.3 x weight (kg) x base deficit

      • hyperosmolarity, hypocalcemia, hypernatremia, left-ward shift of the oxyhemoglobin dissociation curve

     Electrolytes  Calcium is important for cardiac function and for the pressor effect of catecholamines
    • Electrolytes

      • Calcium is important for cardiac function and for the pressor effect of catecholamines

      • Hypoglycemia can lead to CNS damage and is needed for proper cardiovascular function

      • Check the BUN and creatinine to evaluate renal function

      • Hyperkalemia can occur from renal dysfunction and/or acidosis

    Congenital adrenal hyperplasia  Infant presents in shock, usually in the second week of life, typically

    Congenital adrenal hyperplasia

    • Infant presents in shock, usually in the second week of life, typically a boy, with metabolic acidosis, hyponatremia, hypoglycemia, and hyperkalemia

    Hyperammonemia

    • mild elevations are common with shock

    • levels > 1000 are consistent with inborn errors of metabolism

    • consider Reye Syndrome, toxins, hepatic failure

     Look for etiology of shock  Evaluate hemoglobin, hematocrit, and platelet count  Should be
    • Look for etiology of shock

    • Evaluate hemoglobin, hematocrit, and platelet count

      • Should be followed as these values may drop after fluid resuscitation

    • Shock from any etiology can lead to DIC and end organ damage

      • CBC, PT, INR, PTT, Fibrinogen, Factor V, Factor VIII, D- dimer, and/or FDPs

      • Check LFT’s, follow CNS and pulmonary status

     Think about inborn errors of metabolism  Lactate and pyruvate  Ammonium, LFTs  Plasma
    • Think about inborn errors of metabolism

      • Lactate and pyruvate

      • Ammonium, LFTs

      • Plasma amino acids, urine organic acids

      • Urinalysis with reducing substances

      • Urine tox screen

     Goal of therapy is identification, evaluation, and treatment of shock in its earliest stage 
    • Goal of therapy is identification, evaluation, and treatment of shock in its earliest stage

    • Initial priorities are for the ABC’s

    • Fluid resuscitation begins with 20cc/kg of crystalloid or 10cc/kg of colloid

    • Subsequent treatment depends on the etiology of shock and the patient’s hemodynamic condition

    • Successful resuscitation depends on early and judicious intervention