Treatment of Shock

00:01 Memorizing these vital signs is not important, but I bring it up to remind you that in pediatrics, we have the unique problem of needing to know what is a normal heart rate, a normal respiratory rate and a normal blood pressure for infants and children as these numbers change as we get older.

00:20 So younger infants generally have a higher heart rate and respiratory rate and a lower blood pressure as a normal value than older kids.

00:29 Remember, airway, breathing, circulation, this is where you’re going to get a lot of that information and having a sense of what are normal values is important.

00:38 So spend some time looking this chart over as you’re familiarizing yourself with vital signs in children.

00:46 So what are the things we need to do? A patient comes in with shock, generally the first thing we need to do is support that circulation.

00:55 So obviously, if there’s an obstructive shock, before we’re giving IV fluids, we need to do an emergent fix of the obstruction.

01:05 So for example, in a tension pneumothorax, before giving IV fluids, we really need to do a needle compression and you can check how to do that in our tension pneumothorax lecture.

01:16 After those immediate interventions, we typically would give boluses.

01:21 And the amount of bolus is 20 cc’s per kilo.

01:25 You should memorize that number.

01:26 And we usually give that over 20 minutes, but you can certainly give it faster in a patient with acute hypovolemic shock.

01:33 We may repeat these boluses up to usually once, sometimes twice, rarely three times.

01:41 By the time you’re giving a fourth bolus, you’re probably making a mistake.

01:46 These patients now probably aren’t that dehydrated or hypovolemic unless there’s ongoing losses and you might consider another approach towards maintaining a higher pressure.

01:58 The reason being is you can actually fluid overload with someone who is in shock.

02:04 And if you fluid overload them, the lungs become filled with fluid and they can be harder to engage in the resuscitation in terms of the acid-base status with the breathing.

02:14 So you don’t want to make things worse.

02:16 So after three boluses, you should start to think about alternative methods for maintaining blood pressure support.

02:23 So what are those? Well, generally, in children, we start with dopamine.

02:27 So, dopamine has both beta 1 and beta 2 effects and it is a first line pressor supportive drug for children.

02:36 It increases also cardiac output, which can’t hurt.

02:40 And it increases the systemic vascular resistance.

02:44 Other options include for anaphylactic shock, we’ll give epinephrine.

02:48 We sometimes give norepinephrine for a warm distributive shock, though norepinephrine is rarely a first-line agent for blood pressure support and for cardiogenic shock, we may give dobutamine.

03:02 Sometimes we’re not sure what’s going in before the dopamine is already on board and then we can switch agents.

03:08 So that’s my review of the management of shock in children.

03:12 Thanks for your attention.