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.