Initial evaluation of

shock
in children
Silvia triratna
Divisi pediatri gawat darurat
Bagian Ilmu Kesehatan Anak FK UNSRI/ RSUP
Moh Hoesin Palembang

Shock
a dynamic and unstable
pathophysiologic state
characterized by inadequate
tissue perfusion.

 Inadequate peripheral perfusion

where oxygen delivery does not
meet metabolic demand

Initially,
the effects of inadequate
perfusion are reversible
3

prolonged oxygen deprivation

generalized cellular hypoxia
disruption of critical biochemical
processes
cell membrane ion pump dysfunction
intracellular edema,
inadequate regulation of intracellular pH,
cell death.
4

 Aggressive treatment within

the first few hours

after
presentation may prevent the
invariable progression and poor of
shock

Children can effectively compensate

for circulatory dysfunction
heart rate,
systemic vascular
resistance,
and venous tone,

maintaining
normal blood
pressures
despite

hypotens
ion is a
very late
6

 Although the cause of shock

may not be initially apparent,
treatment must begin
immediately

what should the clinician

do ??
7

 The clinician should be able to

recognize recognize children in
shock early before they develop
hypotension,
when they are more likely to respond
favorably to treatment
The KEY is

EVALUATION
8

The goals of the initial evaluation

of shock in children include
Immediate identification of lifethreatening conditions
Rapid recognition of circulatory
compromise
Early classification of the type and
cause of shock

A systematic approach to the evaluation of children with

evidence of poor perfusion

Identifies features of the history,

Physical examination,
Ancillary studies that suggest the
etiology of the underlying condition

10

Etiology
Decreased intravascular
volume,
Abnormal distribution of
intravascular volume
and/or impaired
cardiovascular function.
11

CLASSIFICATION
is based on the physiologic
mechanisms that result in decreased
tissue perfusion

12

Classification of Shock

Shock

Hypovolaemic

Neurogenic

Cardiogenic

Distributive

Anaphylactic

Septic

STAGES OF SHOCK
Compensated shock
Heart rate is initially increased. S
signs of peripheral vasoconstriction (such as cool skin, decreased
peripheral pulses, and oliguria)
Normal Blood pressue
Decompensated shock
Signs and symptoms of organ dysfunction (such as altered mental
status as the result of poor brain perfusion) appear.
Systolic blood pressure falls,
Irreversible shock During this stage, progressive end-organ
dysfunction leads to irreversible organ damage and death. The
process is often irreversible, despite resuscitative efforts
15

STAGES OF SHOCK
Compensated shock
Heart rate is initially increased.
signs of peripheral vasoconstriction (such as cool skin, decreased
peripheral pulses, and oliguria)
Normal Blood pressue

Decompensated shock
Signs and symptoms of organ dysfunction (such as altered mental status
as the result of poor brain perfusion) appear.
Systolic blood pressure falls,

Irreversible shock
progressive end-organ dysfunction leads to irreversible organ damage
and death.
The process is often irreversible, despite resuscitative efforts
16

Children with lifethreatening conditions,

hypotension, and
compensated shock (eg,
poor perfusion with a normal
blood pressure)
should be recognized from
an initial rapid assessment
of appearance, breathing,

MENENTUKAN
ANAK SAKIT GAWAT
PAT

MELIHAT KEADAAN ANAK

GENERAL ASSESSMENT

PENILAIAN ABCDE

INITIAL ASSESSMENT

18

LA

Suara nafas
abnormal
Posisi abnormal
Retraksi
Napas cuping
hidung

AS

PE

AF

NA

PI

AY

T = Tonus
I =
Interactiveness
C = Consolability
L = Look/Gaze
S = Speech/Cry

UP

S E G I T I G A P E N I L A I A N P E D I AT R I K
( PEDIATRIC ASSESSMENT TRIANGLE = PAT)

SIRKULASI KULIT
Pucat

Mottled

Sianosi
s
19

MEANS SHOCK

N
al
m
or

al ce
rm ran
o
n a
Ab ppe
A

Poor Circulation to Skin

20

 After completing the Triangle,

begin a more complete
pediatric primary survey.
DISABILITY
CIRCULATION
BREATHING

AIRWAY

21

22

Respiratory Effects
Remember that the cardiovascular and
respiratory systems work together Tachypnoea is one of the first signs that
reflects reduced blood flow and oxygen
transport.

23

CIRCULATION
Poor perfusion can often be
identified rapidly, before a blood
pressure measurement is taken.
Features of circulation that should
be quickly evaluated i

24

Quality of central and

peripheral pulses
Decreased intensity of distal pulses
in comparison to central pulses
suggests peripheral vasoconstriction
and compensated shock.

25

Skin temperature
Skin may be cool in children with
compensated shock, but this finding
can also be influenced by
environmental temperature.

26

Capillary refill
Capillary refill greater than two
seconds suggests shock.
Flash capillary refill suggest septic
shock

27

28

Heart rate Tachycardia signs of compansated shock

A normal heart rate with signs of
compensated shock can occur
spinal cord injury.
Hypoxia and
beta blockers and calcium channel
blockers) can cause bradycardia
Bradycardia can also be an agonal event
for patients with shock from any cause.
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Heart rates in normal children

Age
Newborn to 3
months
3 months to 2
years
2 years to 10
years
>10 years

Awake rate

Mean

Sleeping
rate

85-205

140

80-160

100-190

140

75-160

60-140

80

60-90

60-100

75

50-90
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circulation

31

Skin Signs
Feel for
temperature
and
moisture

Estimate
capillary
refill.
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33

34

35

Blood pressure
- Children with shock may have
normal blood pressures.
Hypotension must be rapidly
identified, because those with low
blood pressures typically deteriorate
rapidly to cardiovascular collapse
and cardiopulmonary arrest
For children with normal systolic
blood pressures, the classification of
36
shock may be suggested by

 Narrow pulse pressure occurs when

diastolic blood pressure is increased
as the result of a compensatory
increase in systemic vascular
resistance (such as with
hypovolemic and cardiogenic
shock).
Widening of pulse pressure can be
seen when diastolic blood pressure
is decreased as the result of
decreased systemic vascular37

TEKANAN SISTOLIK MINIMAL

70 + { 2 x umur (tahun) }

38

Normal Bood Pressure

for children
Age

0 28 day
FT
1 12 mo
1 10 y
> 10 y

Systolic BP

> 60
> 70
70 + 2 x age in y
> 90
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Temperature
Fever (or hypothermia in
young infants) is often
consistent with septic shock.

40

DISABILITY
STATUS NEUROLOGIK

SKALA AVPU
SKALA COMA GLASGOW
POSTUR
PUPIL
41

A V P U
CARA CEPAT MENILAI KESADARAN

ALERT

RESPONS TO VOICE

RESPONS TO PAIN

UN RESPONSIVE
42

MANAGEMENT

supportive care
resuscitation,
monitoring
septic shock broad spectrum
initial antimicrobial therapy
Metobolic

43

 PALS septic shock algorithm

44

PALS
septi
c
shoc
k
algori
thm

45

TINDAKAN LANJUT
PAT
ABCD

MENERUSKAN RESUSITASI
PEMERIKSAAN /PEMANTAUAN
LEBIH LANJUT
MERUJUK

46

Key Issues In Shock

Recognise and treat early (during compensatory phase)
Increased resp. rate,
Restlessness,
Early
Anxiety,
signs of
Argumentative
shock
Falling BP = Late sign of shock
Pallor, tachycardia and slow capillary refill = Shock until
proven otherwise
Hallmark symptoms are:
Decreased BP
Increased HR
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