(PALS) Pediatric Shock Overview – Part 3
General Management of Pediatric Shock:
During the shock state, the body’s compensatory mechanisms are largely directed at optimizing the balance between oxygen delivery and consumption. Likewise, therapeutic efforts should be directed at the same.
Rapid optimization of the balance between oxygen delivery and consumption is critical.
There are 4 general actions that should take place regardless of the type of shock. These are:
- Improve cardiac output. (Click for details.)
- Treatments to improve cardiac output are generally guided by the type of shock, but usually involve rapid intravascular volume expansion with the use of isotonic crystalloid IV fluids. This is referred to as fluid resuscitation and is reviewed thoroughly within on each page for the specific type of shock.
- Obtain IV or IO (intraosseous) access.
- Medications that increase heart rate, or improve preload, afterload, and contractility may be given (examples of these medications may be reviewed under each specific type of shock)
- Improve the level of oxygen in the blood. (Click for details.)
- Treatments to improve the level of oxygen in the blood include: Delivery of 100% oxygen by non-rebreather mask; Invasive or non-invasive mechanical ventilation (CPAP or ventilator)
- It also may be necessary to improve the oxygen carrying capacity of the blood by giving transfusions of packed red blood cells.
- Decrease the body’s oxygen demand. (Click for details.)
- Ensure the comfort of the alert child. This will help reduce the oxygen demand and also decrease the child’s anxiety as you carry out the assessments and interventions.
- Treatments that will decrease the bodies demand for oxygen include the following: reduce fevers, pain and anxiety levels, and decrease work of breathing.
- Direct treatments include: administer fever reducing medications, administer pain and anxiety medication, and use non-invasive ventilation or intubation and mechanical ventilation to reduce the metabolic demand.
- Normalize metabolic and electrolyte imbalances. (Click for details.)
- Treatments may involve correction of metabolic acidosis, hypoglycemia, hypocalcemia, and hyperkalemia.
The PALS systematic approach algorithm should generally direct the management and treatment of the pediatric shock patient, and frequent reassessment should occur as interventions are implemented.
Therapeutic treatments and goals for shock should be guided by the Evaluate → Identify→ Intervene Sequence of the Systematic Approach Algorithm.
Therapeutic goals that indicate treatments are effective include:
- Improved mental status
- Improved BP
- Improved HR
- Normal and equal central and peripheral pulses
- Improved capillary refill < 2 seconds
- Warming extremities
- Improvement in important laboratory studies (ie. Lactate Level)
Normalization of the above therapeutic goals would be the indication that treatments are effective for improving oxygen/nutrient delivery and consumption.
Important Laboratory Values for Evaluation of Shock:
Within the Evaluate portion of the Evaluate → Identify→ Intervene sequence of the Systematic Approach Algorithm, there are laboratory studies that provide information which will direct further interventions for the treatment of shock. Lactate, CBC, ABG, Central venous oxygen saturation, Potassium, Calcium, and Glucose.
- Lactate (Lactic Acid): (Click for details.)
- Arterial lactate is typically elevated during a shock state. This elevation is normally caused by metabolic acidosis resulting from inadequate oxygen delivery, disproportionate oxygen demand, and/or diminished oxygen use.
- Normal arterial lactate levels are < 18 mg/dl (2 mmol/L). Elevated lactate levels range from approx 18-45 mg/dl (<2.5 mmol/L).
- A high lactate level is a typical finding with septic shock, but can be present with any type shock since all types of shock are a result of inadequate oxygen delivery to the tissues and organs.
- When there is inadequate oxygen delivery to the tissues, anaerobic metabolism leads to an over production and build-up of lactic acid.
- When a state of shock is improving there should be a trend in the lactate level to decrease toward the normal level of < 18 mg/dl (2.5 mmol/L). With regard to the treatment and evaluation of shock, a downward trend of the lactate level is more important than the actual number value.
- Complete Blood Count (CBC): (Click for details.)
- There are 4 components of the CBC that are of primary concern. The hemoglobin, hematocrit, white blood cell count, and the platelet count.
- A low hemoglobin and hematocrit will be an indicator of blood and/or fluid loss and will help determine fluid resuscitation effects and blood product administration effects.
- White blood cell count aids in the evaluation and treatment of sepsis.
- Platelet count is an indicator of decreased platelet production and disseminated intravascular coagulation (DIC).
- Arterial Blood Gas (ABG): (Click for details.)
- The arterial blood gas allows for the evaluation of both acidosis and alkalosis and can be used to help pinpoint both metabolic and respiratory conditions.
- The ABG is also used as an evaluation tool to determine if treatments are effective for reversing acidotic and alkalotic states.
- If the treatment of shock is effective and there is improved oxygen delivery to the tissues and organs then there will be a trend in the ABG toward a normal pH of 7.35-7.45.
- Potassium: (Click for details.)
- Either elevated (hyperkalemia) or decreased (Hypokalemia) levels of potassium may be present when shock occurs in the critically ill child.
- Both hyperkalemia and hypokalemia should be corrected.
- More importantly, the cause of the shock should be corrected (i.e. metabolic acidosis which occurs with shock can cause hyperkalemia. When the shock is corrected the potassium level will normalize.)
- Ionized Calcium: (Click for details.)
- The administration of blood products and particularly cold blood products can result in a severe decrease in ionized calcium levels (hypocalcemia).
- Hypocalcemia can occur when sepsis is present.
- Hypocalcemia can result in myocardial dysfunction and severe hypotension and should be evaluated regularly and treated aggressively.
- Central venous oxygen saturation (Scvo2): (Click for details.)
- Central venous oxygen saturation can provided information about oxygen consumption and delivery that can guide the course of treatment for shock.
- When oxygen delivery to the tissues is decreased (shock), the tissues remove a proportionately larger amount of oxygen from the hemoglobin. This results in a lower central venous oxygen saturation because more oxygen has been removed by the tissues in an attempt to compensate for the decreased oxygen delivered to the tissues.
- When central venous oxygen saturation is low it is an indicator that oxygen delivery is inadequate. When central venous oxygen saturation is high, it is an indicator that there is a maldistribution of blood or decreased oxygen utilization.
- Glucose: (Click for details.)
- Hypoglycemia and hyperglycemia are relatively common occurrences in the critically ill child.
- Hypoglycemia may even be the primary cause or a contributing factor to an ongoing shock state or a change in a child’s level of consciousness.
- A rapid blood glucose check should be performed in the critically ill child and either condition should be managed to maintain a blood glucose level to within normal parameters.
- Hypoglycemia should be treated with IV dextrose.
- Hyperglycemia may require treatment and this is depended upon in the discretion of the medical provider and hospital protocol.