CMC COMPENDIUM
  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Fellowships at CMC
    • Ultrasound
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
  • PEOPLE
    • Program Leadership
    • Current Chiefs
    • PGY-3
    • PGY-2
    • PGY-1
    • Recent Grads >
      • Class of 2023
      • Class of 2022
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Incentive Shifts & Moonlighting >
      • AEC Incentive Shifts
      • STICU Moonlighting
      • MICU X moonlighting
      • Cardiac Rehab >
        • Pineville Cardiac Rehab
        • Union Cardiac Rehab
    • Schedules >
      • Block Schedule
      • ED Shift Schedule
      • Conference and Resident Lectures
      • Journal Club
      • CQR
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction
    • Off Service Rotators

Pre-PICU Prep - Dr. Sean Fox

7/21/2017

0 Comments

 
Picture
Shock: Recognition
  • There is no single pathognomonic finding that defines shock.
  • Hypotension is a late finding, but an ominous one, in kids.
  • Constellation of findings:
  1. Tachycardia
  2. Tachypnea
  3. Poor perfusion
  4. Poor pulse quality
  5. Altered mental status
  • Cold Shock findings:
  1. High Systemic Vascular Resistance
  2. Cold, clammy, mottled, or cyanotic extremities
  3. Capillary Refill > 2 seconds
  4. Diminished / thready pulses
  5. Narrow pulse pressure.
  • Respect the “just ain’t right” findings:
  1. Poor feeding
  2. Jittery
  3. Irritable
  4. Lethargic 
Be Aggressive Early
  • Once recognized, be aggressive within 1st hour!
  • IV or IO 40-60 ml/kg of isotonic fluids PUSHED rapidly
  1. Do not hang to gravity or on a “pump.”
  2. Use syringe pushes or pressure bags
  3. Children commonly will require 40-60 ml/kg in the 1st hour, but may require more (some say 200 ml/kg in 1st hour in right clinical setting). 
  • Don’t forget about Glucose! 
  • Optimize oxygenation
  1. Supplemental may be all that is initially needed.
  2. 30-40% of a child’s cardiac output goes to the work of breathing when critically ill, so often will require additional support (i.e., intubation).
  • Broad spectrum antibiotics
Fluid-Refractory Shock
  • Keep your Differential open!
    • While ordering empiric antibiotics, consider the other causes of SHOCK in children.
    • The child with fluid-refractory shock deserves a second and third consideration for the other possible culprits!
  • Use your bedside Ultrasound
  1. Pericardial Effusion & Tamponade?
  2. Overview of heart function / squeeze / size
  3. IVC volume? – perhaps more fluids aren’t the answer
  4. Pneumothorax?
  5. Free intra-abdominal fluid? – Is there occult trauma??
Vasopressors can be Started Peripherally
  • Do not hesitate to start vasopressors.
    • Children with fluid-refractory shock tend to respond to inotropes. 
    • Reversing shock is associated with better survival.
  • Common perception is that vasoactive medications (vasopressors) need to be give via central line.
    • In an ideal setting, this is reasonable. That 1st hour of critical illness is often not ideal.
    • There is no data clarifying whether one vasopressor is more harmful when given peripherally than another. 
  • Epinephrine has been shown to be safe and effective when given via peripheral IV or IO in the setting of Septic Shock.  [Ramaswamy, 2016; Ventura, 2015]
  • Time is critical; central lines aren’t easy in children; PIVs and IOs work just fine! 
 


0 Comments

Your comment will be posted after it is approved.


Leave a Reply.

    Archives

    August 2018
    February 2018
    January 2018
    December 2017
    October 2017
    September 2017
    August 2017
    July 2017
    June 2017
    May 2017
    April 2017
    March 2017
    February 2017
    January 2017
    December 2016
    November 2016
    October 2016
    September 2016
    August 2016
    July 2016
    June 2016
    May 2016
    April 2016
    March 2016
    February 2016
    January 2016
    December 2015
    November 2015
    October 2015
    September 2015
    August 2015
    July 2015
    June 2015
    May 2015
    April 2015
    March 2015
    February 2015
    January 2015
    December 2014
    November 2014
    October 2014
    September 2014
    August 2014
    July 2014
    June 2014
    May 2014
    April 2014
    March 2014
    February 2014
    January 2014
    December 2013
    November 2013
    October 2013
    September 2013
    August 2013
    July 2013

    Categories

    All
    Abdominal Pain
    Abdominal-pain
    Airway
    Back Pain
    Back Pain
    Bleeding
    Change-in-mental-status
    Chest Pain
    Dizziness
    Ecg
    Emboli
    Environmental
    Fever
    Gyn
    Headache
    Hypertension
    Infectious Disease
    Pain
    Pediatric Emergency
    Professionalism
    Psych
    Respiratory Distress
    Sepsis
    Shock
    Toxins
    Trauma
    Vomiting
    Weakness

    RSS Feed

    Tweets by @PedEMMorsels
Powered by Create your own unique website with customizable templates.
  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Fellowships at CMC
    • Ultrasound
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
  • PEOPLE
    • Program Leadership
    • Current Chiefs
    • PGY-3
    • PGY-2
    • PGY-1
    • Recent Grads >
      • Class of 2023
      • Class of 2022
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Incentive Shifts & Moonlighting >
      • AEC Incentive Shifts
      • STICU Moonlighting
      • MICU X moonlighting
      • Cardiac Rehab >
        • Pineville Cardiac Rehab
        • Union Cardiac Rehab
    • Schedules >
      • Block Schedule
      • ED Shift Schedule
      • Conference and Resident Lectures
      • Journal Club
      • CQR
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction
    • Off Service Rotators