Shock in Pediatrics
Shock is usually manifested when there is presence of significant cardiovascular dysfunction. Any discrepancy in cardiovascular function leads to inadequate oxygen delivery and perfusion to vital organs. When this happens, anaerobic metabolism occurs and lactic acid is produced. If shock remains untreated, it may eventually lead to cellular destruction and multi-organ failure, which is dramatically morbid and fatal to the pediatric population. Therefore a keen and ardent assessment is vital, coupled with an aggressive treatment to improve prognosis and prevent fatalities.
Classification
- Hypovolemic Shock – occurs secondary to an intravascular volume loss, so far the most common among the three
- Distributive Shock – occurs secondary to vasomotor instability or capillary leak
- Cardiogenic shock- caused primarily by a cardiac pump dysfunction
Any of these classification pose a critical state for all pediatric patient, therefore, interventions should be ready at hand especially skills and knowledge of basic life support which includes the airway, breathing and circulation.
Causes
- Fluid and electrolyte losses
- Vomiting
- Diarrhea
- Inadequate water or fluid intake
- Excessive use of diuretics
- Heat stroke
- Hemorrhage
- Trauma
- Fractures (long bones)
- Surgical blood loss
- Lacerations
- Plasma losses
- Burns
- Sepsis (systemic infection form bacteria, viruses and fugi)
- Intestinal obstruction
- Endocrine
- Diabetes mellitus
- Diabetes insipidus
- Allergy
- Congenital heart disease
- Cardiomyopathy
- Myocarditis
- Arrhythmias
- Drug toxicity
Clinical Manifestations
Poor perfusion:
- Cool extremities
- Diminished or absent distal pulses
- Capillary refill > 3 seconds
- Mottling of the skin
Blood flow shunted away:
- Mottling of extremities
- Mottling of the trunk
Distributive shock:
- Warm skin
- Flushed skin
- Tachycardia
- Tachypnea
Respiratory:
- Increased breathing
- Increased respiratory rate
- Retractions
- Nasal flaring
Neurologic:
- Irritable
Anaphylactic Shock:
- Severe hypotension
- Urticaria
- Swollen lips
- Airway swelling
- Respiratory difficulties
Diagnosis
- History taking: previous illness
- Complete blood count
- Electrolyte level count
- Blood gas test
- Blood cultures
- Chest x-rays (will evaluate heart size)
- Echocardiogram (evaluate cardiac size and function)
Management
- Early detection and prompt therapy can improve the survival and prognosis of a child with shock.
- Oxygen inhalation supplementation via nasal cannula or face mask improves ventilation and oxygen perfusion.
- Endotracheal intubation is indicated if indeed, the child is unable to support his breathing and ventilation.
- Hypovolemic and septic shock patients require strict volume replacement; IV lines are attached to facilitate rapid fluid resuscitation. Usually, crystalloid fluids are given like Lactated Ringer’s or normal saline.
- Blood transfusion is initiated if shock has been due to accidents or sever trauma.
- After volume resuscitation is achieved, inotropic support is initiated. To improve cardiac output, dopamine and dobutamine is given. To increases systemic vascular resistance and support blood pressure, epinephrine or norepinephrine is given.
- For septic shock, antibiotic therapy is initiated.
Byron Webb Romero, RN, MSN
Finished BSN at Lyceum of the Philippines University, and Master of Science in Nursing Major in Adult Health Nursing at the University of the East Ramon Magsaysay Memorial Medical Center. Currently working at Manila Doctors College of Nursing as a Team Leader for Level I and II, Lecturer for Professional Nursing Subjects, and also a Clinical Instructor.
