Shock in children
Shock is an unstable physiological state that occurs following acute failure of the circulation, which results in inadequate tissue perfusion and oxygenation and incomplete removal of harmful metabolic waste products.
Article by Mike Stephenson
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Key Points
- Understand the different types of shock in children, their mechanisms and effects.
- Be aware of the stages of shock and the physiological response.
- Consider the rationale behind the use of fluids and inotropes in the treatment of shock.
Understanding the five classifications of shock and their effect on the child's circulation supports nurses in playing a vital role in identifying the child in shock. Accurate assessment and physiological monitoring allows the nurse to recognise the underlying cause and initiate an appropriate intervention.
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Definition
Shock is an unstable physiological state that occurs following acute failure of the circulation, which results in inadequate tissue perfusion and oxygenation and incomplete removal of harmful metabolic waste products. Shock leads to a decrease in intravascular volume, a disruption to circulating intravascular volume, or impaired cardiovascular function (Waltzman, 2015).
Recognising shock can be difficult as the signs and symptoms of shock are not those of the underlying disease/process, but the body's attempts to maintain homeostasis by preserving an effective circulation (Cameron et al, 2019). If shock is not recognised, anaerobic metabolism and tissue acidosis will result; if these changes are not reversed, end organ failure will follow (Crisp and Rainbow, 2007).
In this article, ‘children’ will refer to any child or young person up to 16 years of age. However, although infection is recognised as the leading cause of mortality and morbidity in the newborn (Bedford Russell, 2015), early-onset
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Diagnosis
| Table 1. Five classifications of shock and effect on the child's circulation | |||
|
Classification |
Problem |
Cause |
Fluid, pump and vessel |
|
Hypovolaemic |
A loss of circulating volume |
Gastroenteritis, bleeding, vomiting |
Lack of fluid, leading to an empty pump and vessels |
|
Distributive |
Abnormal dilation or constriction of vessels. Dilation is more common |
Sepsis, head injury, anaphylaxis |
Blood volume and pump are normal, abnormal vessels prevent blood from reaching the peripheries |
|
Cardiogenic |
Reduction in cardiac contractility |
Congenital heart disease, pneumothorax, cardiac tamponade |
Blood volume and vessels are normal, heart cannot effectively pump blood through the vessels |
|
Obstructive
|
Abnormal blood flow |
Obstructed vessels, tension pneumothorax or cardiac tamponade |
Blood volume is normal but cannot reach tissues due to an obstruction in vessels or pump |
|
Dissociative
|
Oxygen-carrying capacity of the blood is too low |
Profound anaemia, carbon monoxide poisoning |
Fluid (blood) does not work effectively |
| From: Walzman, 2015; Cameron et al, 2019 | |||
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Overview
Stages of shock
Shock follows three distinct phases and it is imperative the nurse caring for a child recognises the presenting features of each stage. Timely and targeted interventions will reduce the likelihood that a child will reach the final stage where interventions become ineffective and the condition is fatal. The stages are comparable regardless of the classification.
1. Compensated
In the first stage, a series of physiological changes occur to ensure the core essential organs, the brain, heart and lungs, are prioritised in terms of oxygenated blood supply (Waltzman, 2015). Peripheral vessels constrict to minimise blood flow to the extremities and the heart increases the rate of blood flow. At this stage, the child can initially compensate for an inadequate circulation (Jevon, 2012) and maintain end-organ perfusion (Crisp and Rainbow, 2007).
The nurse can observe these changes as the child's heart rate and respirations will increase, peripheral
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Treatment
Fluid
During hypovolaemic and distributive shock, fluid replacement is essential to limit further deterioration. Limited evidence supports the optimal type, rate and volume of fluid to be administered (Dellinger et al, 2008). However, the preferred fluid for resuscitation is isotonic saline (0.9% sodium chloride). Alternatively, Weiss et al (2017) suggested balanced crystalloid solutions that closely resemble serum electrolyte concentrations, containing electrolytes such as potassium chloride and magnesium chloride alongside sodium chloride, may be considered as alternative intravenous fluids.
Colloids, such as human albumin 5%, may appear to be ideal as the larger molecules may remain in the intravascular space longer. However, despite no large-scale studies in children comparing isotonic 0.9% saline with colloid, no significant differences in mortality were found in the SAFE or CRISTAL trials in adults (Finfer et al, 2004; Annane et al, 2013). However, the UK Resuscitation Council (2015) continues to advocate that an initial fluid
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Resources
References
Annane D, Siami S, Jaber S et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients: the CRISTAL randomized trial. JAMA. 2013;310(17):1809-1817. https://doi.org/10.1001/jama.2013.280502
Badheka A, Bangalore Prakash P, Allareddy V. Successful use of extracorporeal membrane oxygenation in a child with obstructive shock due to massive bilateral pulmonary embolism. Perfusion. 2018;33(4):323-325. https://doi.org/10.1177/0267659117736380
Bedford Russell AR. Neonatal sepsis. Paediatrics and Child Health. 2015;25(6):271-275. https://doi.org/10.1016/j.paed.2015.02.005
Bentley J, Henderson S, Thakore S, Donald M, Wang W. Seeking sepsis in the emergency department-identifying barriers to delivery of the sepsis 6. BMJ Qual Improv Rep. 2016;5(1):u206760.w3983. https://doi.org/10.1136/bmjquality.u206760.w3983
Bersten AD, Soni N. Oh's intensive care manual. 5th edn. London: Elsevier; 2003
Brissaud O, Botte A, Cambonie G et al.. Experts' recommendations for the management of cardiogenic shock in children. Ann Intensive Care. 2016;6(1):14. https://doi.org/10.1186/s13613-016-0111-2
Cameron P, Browne G, Mitra B, Dalziel S, Craig S (eds). Textbook of paediatric emergency medicine. (3rd edn). London: Elsevier; 2019
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