Pediatric questions to make you think (#2)!

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MediRounds

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What are the different types of physiologic shock?
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List them. Don't just put a link. That's cheating!
 
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Good! I would classify them a little differently, since there are so many nuances now with better understanding of shock and the different etiologies...just something to think about.

Cardiogenic shock - some would advocate that obstructive shock may be separate (ie. aortic stenosis) from the primary "cardiac" related shock due to muscle pump failure from other causes

Hypovolemic shock

Distributive shock or neurogenic shock (some would advocate listing neurogenic shock separately because distributive shock includes anaphylactic shock and septic shock as well)

Septic shock - because of the specific mechanism of the etiology of the shock

Endocrine shock - adrenal insufficiency is difficult to classify in the other groups

Other etiologies of shock that may be difficult to group include pulmonary embolism and drug toxicity, although drug toxicity can often be put into the distributive shock category or cardiogenic shock group.
 
Now that we've gotten this far, the difficult question is:

What is the physiology of each of the categories of shock? The reason why this is important is because it impacts how you will treat each category of shock.

Any brave souls to answer the question...without just pasting a link to Dr. Google... :)
 
MediRounds said:
Now that we've gotten this far, the difficult question is:

What is the physiology of each of the categories of shock? The reason why this is important is because it impacts how you will treat each category of shock.

Any brave souls to answer the question...without just pasting a link to Dr. Google... :)
Click to expand...

You could always group PE along the lines of an "obstructive" shock like tension pneumo, tamponade, positive pressure associated hypotension (be it from asthma, intubation, CPAP, etc.). But unfortunately while it makes sense physiologically to group these, the treatment for all is completely different, despite having the same basic premise of allowing the ventricles to fill. then again i'm not sure where even the tacchyarhythmic hypotension would get grouped.
 
I agree. While it is nice to be able to group types of shock, it is more important to understand the etiology of the shock. Once you understand the etiology, you can make sense of the physiology...and, ssubsequently, put together a treatment plan.
 
they say the person who understands the subject well is the one who can explain it in simple terms.
hypovolaemic shock. decreased amount of plasma leading to decreased pressure in vessels
cardiogenic shock. poor heart pumping(cardiac output) leading to decreased pressure in vessels
septic shock.
neurogenic. drecreased CO and/ vassodilation
septic shock, vassodilation
 
Internistt said:
they say the person who understands the subject well is the one who can explain it in simple terms.
n
Click to expand...

Thats true, except you suck at it WINK! ;)

Short answer for take aways.

Cardiogenic: either a RATE or a PUMP issue
- Arrythmia - shock fast, pace slow
- Cardiac Output - early reperfusion, dobutamine, milrinone

Hypovolemic: not enough fluid in the tank
- fill tank = fluid and blood

Obstructive something blocking the in or the out
- remove obstruction = IVF vigorously, decompress tension, tPA clot

Distributive: tank is too big for the fluid
- give back vascular tone = Vasopressor +/- steroids

Internistt said:
they say the person who understands the subject well is the one who can explain it in simple terms.
hypovolaemic shock. decreased amount of plasma leading to decreased pressure in vessels
cardiogenic shock. poor heart pumping(cardiac output) leading to decreased pressure in vessels
septic shock.
neurogenic. drecreased CO and/ vassodilation
septic shock, vassodilation
Click to expand...

Long answer for peopel who care. For the love of the holy jesus read an ICU book.

Cardiogenic - EITHER its a heart rate issue OR its a pump issue. If too fast, shock. if too slow, pace. If contractility issue, increase the contractility and decrease the result of low flow (high ang ii and clamped vessels). Acheived with Dobutamine and Dopamine or Milrinone and Vasopressin

Hypovolemic - not enough fluid in the tank. Dehydration , Hemorrhage, whatever. The tank gets clamped down, and hard. Vasopressors are just going to exacerbate the condition, they need fluid and blood.


Obstructive - something is in the way. Either its something in the way preventing inflow (cardiac tamponande, tension pneumo), or its something in the way preventing outflow (PE, atrial myxoma). The goal is to remove the obstruction. In the meantime, increased preload might help.

------DRAW A BIG ASS LINE FROM HERE TO THE ONE BELOW --------

Distributive. This is the all encompassing "vasodilation" shock. Sepsis (from TNF-alpha, Il-1), Anaphylaxis (histamine, mast cells), Spinal Shock (anesthesia, trauma), dysfunctional autonomics (adrenal insufficiency). Whatever the case may be, you need a vasopressor. A pressor. Not "a blood pressure increasing medication." A pressor. Norepi = Dopamine (dopamine a little worse? maybe... see SOAP trial). If pressors are insufficient, add cortisol (relative adrenal insufficiency).


Why did you draw a big ass line? Oh. Because ALL THREE CAUSES of shock not distributive result in vasoconstriction. Distributive shock results from vasodilation. The pathophysiology is COMPLETELY THE OPPOSITE, and can be used for physical exam findings as well as therapeutic interventions. Increasing SVR with pressors in Cardiogenic, Hypovolemic, or Obstructive shock will just make the patient WORSE, where as increasing vasopressors in distributive shock saves lives.

Thus, like i said, look at this site for beginner understanding.

www.onlinemeded.org/shock

P.S. "Neurocardiogenic" is not a type of shock. It is brief, transient, and is a mechanism for SYNCOPE, not shock. Oh look, i found this video too.
 
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OveractiveBrain said:
Thats true, except you suck at it WINK! ;)

Short answer for take aways.

Cardiogenic: either a RATE or a PUMP issue
- Arrythmia - shock fast, pace slow
- Cardiac Output - early reperfusion, dobutamine, milrinone

Hypovolemic: not enough fluid in the tank
- fill tank = fluid and blood

Obstructive something blocking the in or the out
- remove obstruction = IVF vigorously, decompress tension, tPA clot

Distributive: tank is too big for the fluid
- give back vascular tone = Vasopressor +/- steroids



Long answer for peopel who care. For the love of the holy jesus read an ICU book.

Cardiogenic - EITHER its a heart rate issue OR its a pump issue. If too fast, shock. if too slow, pace. If contractility issue, increase the contractility and decrease the result of low flow (high ang ii and clamped vessels). Acheived with Dobutamine and Dopamine or Milrinone and Vasopressin

Hypovolemic - not enough fluid in the tank. Dehydration , Hemorrhage, whatever. The tank gets clamped down, and hard. Vasopressors are just going to exacerbate the condition, they need fluid and blood.


Obstructive - something is in the way. Either its something in the way preventing inflow (cardiac tamponande, tension pneumo), or its something in the way preventing outflow (PE, atrial myxoma). The goal is to remove the obstruction. In the meantime, increased preload might help.

------DRAW A BIG ASS LINE FROM HERE TO THE ONE BELOW --------

Distributive. This is the all encompassing "vasodilation" shock. Sepsis (from TNF-alpha, Il-1), Anaphylaxis (histamine, mast cells), Spinal Shock (anesthesia, trauma), dysfunctional autonomics (adrenal insufficiency). Whatever the case may be, you need a vasopressor. A pressor. Not "a blood pressure increasing medication." A pressor. Norepi = Dopamine (dopamine a little worse? maybe... see SOAP trial). If pressors are insufficient, add cortisol (relative adrenal insufficiency).


Why did you draw a big ass line? Oh. Because ALL THREE CAUSES of shock not distributive result in vasoconstriction. Distributive shock results from vasodilation. The pathophysiology is COMPLETELY THE OPPOSITE, and can be used for physical exam findings as well as therapeutic interventions. Increasing SVR with pressors in Cardiogenic, Hypovolemic, or Obstructive shock will just make the patient WORSE, where as increasing vasopressors in distributive shock saves lives.

Thus, like i said, look at this site for beginner understanding.

www.onlinemeded.org/shock

P.S. "Neurocardiogenic" is not a type of shock. It is brief, transient, and is a mechanism for SYNCOPE, not shock. Oh look, i found this video too.
Click to expand...
check robins basic pathology chapter 4 section about shock. you will be shocked.
oo i just realised i forgot anaphylactic.

here is something you dont know "doctor", things like obstructive shock can be grouped under cardiogenic shock. nice cut and paste by the way.
 
Internistt said:
check robins basic pathology chapter 4 section about shock. you will be shocked.
oo i just realised i forgot anaphylactic.

here is something you dont know "doctor", things like obstructive shock can be grouped under cardiogenic shock. nice cut and paste by the way.
Click to expand...

no need to be rude to him, lol, he was trying to give a more useful explanation from the respect of treatment. I wouldn't group obstructive shock under cardiogenic, regardless of what a book says.. it means that blood is blocked from getting to the ventricles, be it left or right. And then I wouldn't even try to group treatments because they're all different for every cause of obstructive shock. an asthmatic who goes into this when intubated gets taken off the vent and has his chest sat on, the tamponade gets a window or pericardiocentesis, the PE gets tpa'd, etc.

I would also correct him by adding that distributive shock, be it anaphylactic or septic, should be treated with fluids in addition to pressors.

The third thing I would add to this conversation is that cardiogenic shock I would think of as chronotropic/inotropic failure. May not be technically correct. I would say that toxin causes of shock and hyperkalemic causes of shock often fit in here, but do have completely different treatments. Whether it's glucagon or insulin therapy for Beta-blockers, or Calcium for hyperkalemia and CCB induced shock.

I dunno, I guess the more types of shock you deal with, the more subtleties you realize there are. There's a reason critical care medicine is it's own subspecialty.
 
Rendar5 said:
no need to be rude to him, lol, he was trying to give a more useful explanation from the respect of treatment. I wouldn't group obstructive shock under cardiogenic, regardless of what a book says.. it means that blood is blocked from getting to the ventricles, be it left or right. And then I wouldn't even try to group treatments because they're all different for every cause of obstructive shock. an asthmatic who goes into this when intubated gets taken off the vent and has his chest sat on, the tamponade gets a window or pericardiocentesis, the PE gets tpa'd, etc.

I would also correct him by adding that distributive shock, be it anaphylactic or septic, should be treated with fluids in addition to pressors.

The third thing I would add to this conversation is that cardiogenic shock I would think of as chronotropic/inotropic failure. May not be technically correct. I would say that toxin causes of shock and hyperkalemic causes of shock often fit in here, but do have completely different treatments. Whether it's glucagon or insulin therapy for Beta-blockers, or Calcium for hyperkalemia and CCB induced shock.

I dunno, I guess the more types of shock you deal with, the more subtleties you realize there are. There's a reason critical care medicine is it's own subspecialty.
Click to expand...
actually i prefer his way of doing it. but in medicine things are grouped in different ways. he told me to go read something up as if i was talking about things that don't exist.
 
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Well done, everyone!

Now that we understand the physiology, let's discuss a case...

Johnny is a 5 year old boy with a history of acute lymphoblastic leukemia. He relapsed after treatment and, subsequently, underwent a bone marrow transplant. On day number 25 after transplant, he is still lymphopenic with a WBC of 0.4 and an absolute neutrophil count of close to zero. He presents to the ER with fever (38.9 C), tachycardia, and hypotension (HR = 145, BP = 68/45). He is also tachypneic, but maintaining his oxygen saturations on room air (RR = 32, Sat = 99%). He has no other symptoms...no nausea, vomiting, diarrhea, rashes, bruising, bleeding, or cough. He does have a broviac that was placed prior to starting treatment for his leukemia.

What is your first course of action?
 
That is a great case, and hopefully some students and residents will work it out.

If I wanted to be a smart-ass, though, the real-world answer though is a trick in that the first step isn't medical. It's asking the clerk to page the PICU attending or calling the nearest hospital with a PICU to arrange for transport. Then you start resuscitating as much as you can. Takes 2 seconds to get the ball rolling and delaying this step will kill this child.
 
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Agreed. The more expertise, the better. Getting the ball rolling on transports is key on timely care. But, let's just say the child can't leave the ER because there is a huge snow storm that makes it impossible to transfer any patients in or out of the hospital... :)
 
MediRounds said:
Well done, everyone!

Now that we understand the physiology, let's discuss a case...

Johnny is a 5 year old boy with a history of acute lymphoblastic leukemia. He relapsed after treatment and, subsequently, underwent a bone marrow transplant. On day number 25 after transplant, he is still lymphopenic with a WBC of 0.4 and an absolute neutrophil count of close to zero. He presents to the ER with fever (38.9 C), tachycardia, and hypotension (HR = 145, BP = 68/45). He is also tachypneic, but maintaining his oxygen saturations on room air (RR = 32, Sat = 99%). He has no other symptoms...no nausea, vomiting, diarrhea, rashes, bruising, bleeding, or cough. He does have a broviac that was placed prior to starting treatment for his leukemia.

What is your first course of action?
Click to expand...
Iv, o2, monitor. Advanced airway equipment to the bedside, 20 ml/kg NS bolus (wide open w/ a pressure bag, and then repeat and then repeat again). Accucheck and give dextrose if needed. Blood cultures and rainbow labs, including lactate. Give cefeprime then vancomycin. Place foley, get UA, UCx. Ekg, cxr. Reassess.
 
turkeyjerky said:
Iv, o2, monitor. Advanced airway equipment to the bedside, 20 ml/kg NS bolus (wide open w/ a pressure bag, and then repeat and then repeat again). Accucheck and give dextrose if needed. Blood cultures and rainbow labs, including lactate. Give cefeprime then vancomycin. Place foley, get UA, UCx. Ekg, cxr. Reassess.
Click to expand...

He came in with IV access, what do you do with that?
What dose of IV antibiotics?
 
Good question about the IV access. The patient has a broviac and the tip is possibly in the SVC/RA junction. This may help you tailor your therapy.
 
Also, any importance on when you give the antibiotics?
 
Rendar5 said:
He came in with IV access, what do you do with that?
What dose of IV antibiotics?
Click to expand...
Keep it and use it. Are there signs of catheter site infection? How many lumens and what gauge? Vanc 15mg/kg and Cefepime 50 mg/kg (obviously, institution dependent and you might use zosyn, meropenem or ceftazidime w/ equal efficacy).
 
turkeyjerky said:
Keep it and use it. Are there signs of catheter site infection? How many lumens and what gauge? Vanc 15mg/kg and Cefepime 50 mg/kg (obviously, institution dependent and you might use zosyn, meropenem or ceftazidime w/ equal efficacy).
Click to expand...

These are questions I don't know the right answer to off the top of my head and I would honestly curbside PedsOnc or PedsICU if I had the option. Each has two options and a clinical reasoning behind each option: Can keep the line for use, or pull the line. Cefepime can be 50mg/kg or 100mg/kg.
 
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I've been told that for septic shock you give bolus IVF at least 3-5 L before moving to vasopressors (unless BP continues to drop even w/ IVF). There's an argument for IVF bolus post 5L but at some point it seems like diminishing returns.

As for the case of febrile neutropenia, I don't know exactly what to do, but something along the lines of emergent treatment. Haven't had Peds yet and it is rarer in adults.
 
evilbooyaa said:
I've been told that for septic shock you give bolus IVF at least 3-5 L before moving to vasopressors (unless BP continues to drop even w/ IVF). There's an argument for IVF bolus post 5L but at some point it seems like diminishing returns.

As for the case of febrile neutropenia, I don't know exactly what to do, but something along the lines of emergent treatment. Haven't had Peds yet and it is rarer in adults.
Click to expand...

Keep in mind this is a 5 year old, not an adult. Peds needs to have weight-based dosing. A bolus of fluid in an adult is 1L. A bolus of fluid in a kid is 10-20cc/kg. So your average bolus for a 5 year old is gonna be around 250cc-400cc.

You're not wrong about adults, btw. Some ppl will use the CVP to indicate when you can stop giving fluids and add pressors. What I would say is that you give boluses until it stops working, then you add pressors.
 
MediRounds said:
Good discussion! Here is an article that summarizes pediatric septic shock guidelines:

http://emedicine.medscape.com/article/2072410-overview

The actual article is in Critical Care Medicine:

http://journals.lww.com/ccmjournal/...l_practice_parameters_for_hemodynamic.39.aspx

Thanks to everyone for taking part in this! Further comments are still welcome... :)
Click to expand...

Only further comment from my experience:
1. if your pediatric neutropenic fever patient has any complaints of joint pain, please just add penicillin G to the antibx regimen. Seen two patients at my own hospital die with gas gangrene that wasn't clinically evident early.
2. start pressors early while still fluid resuscitating the patient unless their BP completely resolves by the third bolus. Which pressor you use doesn't matter so much, everyone has their own opinion. You shoudl establish if these are needed within the hour
3. start antibx right after blood cultures are drawn off, and make sure all established lines have a blood culture drawn from them, whether it's a PICC, a mediport, a Broviac, or what have you.
4. If they're going to be stuck in your care for awhile, talk with your intensivist and oncologist about pulling the line. All sources of sepsis need to be removed at some point.
 
Rendar5 said:
Keep in mind this is a 5 year old, not an adult. Peds needs to have weight-based dosing. A bolus of fluid in an adult is 1L. A bolus of fluid in a kid is 10-20cc/kg. So your average bolus for a 5 year old is gonna be around 250cc-400cc.

You're not wrong about adults, btw. Some ppl will use the CVP to indicate when you can stop giving fluids and add pressors. What I would say is that you give boluses until it stops working, then you add pressors.
Click to expand...

True, I guess I was speaking more in terms of adults, the only patients I've treated so far.

I haven't had exposure to pediatrics yet, so the idea behind weight/surface area-dosing isn't fully ingrained in my head. Thanks for the refresher.
 
Rendar5 said:
Only further comment from my experience:
1. if your pediatric neutropenic fever patient has any complaints of joint pain, please just add penicillin G to the antibx regimen. Seen two patients at my own hospital die with gas gangrene that wasn't clinically evident early.
2. start pressors early while still fluid resuscitating the patient unless their BP completely resolves by the third bolus. Which pressor you use doesn't matter so much, everyone has their own opinion. You shoudl establish if these are needed within the hour
3. start antibx right after blood cultures are drawn off, and make sure all established lines have a blood culture drawn from them, whether it's a PICC, a mediport, a Broviac, or what have you.
4. If they're going to be stuck in your care for awhile, talk with your intensivist and oncologist about pulling the line. All sources of sepsis need to be removed at some point.
Click to expand...

Great points! I can't emphasize enough about rapid fluid administration and getting antibiotics in within the hour of presentation if possible...great discussion! Thank you all for your participation!
 
evilbooyaa said:
True, I guess I was speaking more in terms of adults, the only patients I've treated so far.

I haven't had exposure to pediatrics yet, so the idea behind weight/surface area-dosing isn't fully ingrained in my head. Thanks for the refresher.
Click to expand...

weight based dosing is useful for adults too :) Let's you properly dose narcotics and drips.

Since I now realize that Medirounds is a PICU attending, what would you do with the Broviac? pull it or use it, or leave that decision to the blood culture results?
 
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Rendar5 said:
weight based dosing is useful for adults too :) Let's you properly dose narcotics and drips.

Since I now realize that Medirounds is a PICU attending, what would you do with the Broviac? pull it or use it, or leave that decision to the blood culture results?
Click to expand...

What gave it away... :)

I would treat through the broviac and use it to measure the CVP and check the venous saturation to assess oxygen delivery. I would try to get the venous sat > 70 %. This will also give me an idea of how badly the heart is affected. It is not uncommon for septic shock patients to develop cardiac dysfunction and need a shift in the management plan to give the patient more cardiac support. I wouldn't pull the broviac unless the cultures were repeatedly positive. Oncologic patient come in with line infections causing sepsis or septic shock fairly often.
 
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