Pediatric emergencies (SHOCK & COMA)

Dr Mubarak Abdelrahman Assistant Professor Jazan University

Case 1 An alert, 6-month-old male has a history of vomiting and diarrhea. He appears pale and has an RR of 45 breaths per minute, HR of 180 beats per minute, and a systolic blood pressure of 85 mm Hg. His extremities are cool and mottled with a capillary refill time of 4 seconds. 1. What would best describe his circulatory status? Early (compensated) shock caused by hypovolemia. 2. What is the appropriate initial management for

this child? Placement of an intravenous (IV) line, fluid bolus of 20 ml/kg of normal saline.

• Shock is a syndrome = inability to provide sufficient oxygenated blood to tissues.

• Oxygen delivery is related to: - The arterial oxygen content (oxygen saturation

and hemoglobin concentration). - The cardiac output (stroke volume, heart rate,

and systemic vascular resistance).

SHOCK Definition:

Common Causes

Primary Circulatory Derangement Type

Decreased circulating blood volume Hypovolemic

Vasodilation → venous pooling → decreased preload Maldistribution of regional blood flow

Distributive

Decreased myocardial contractility Cardiogenic

Mechanical obstruction to ventricular outflow Obstructive

Oxygen not released from hemoglobin Methemoglobinemia

Dissociative

Classification of Shock and Common Underlying Causes

CLINICAL MANIFESTATIONS

• All forms of shock produce evidence of insufficient tissue perfusion and oxygenation (increased heart rate, abnormal blood pressure, alterations of peripheral pulses).

• The etiology of shock may alter the initial presentation.

Hypovolemic Shock

Clinical manifestations include :

- Changes in mental status, tachypnea, ….

- Signs of dehydration (dry mucous membranes, decreased urine output)

- Blood loss (pallor).

Cardiogenic Shock

- The liver is usually enlarged,

- a gallop,

- jugular venous distention may be noted.

- oliguria and peripheral edema.

Obstructive Shock

‐ The pulse pressure is narrow (pulses harder to feel).

‐ The liver is often enlarged.

‐ The jugular venous distention may be evident.

Distributive Shock

• In early stages, cytokine release results in vasodilatation = bounding pulses and vital organ function may be maintained

(alert, rapid capillary refill; warm shock).

• If the etiology is sepsis: fever, lethargy, petechiae, …

Septic shock

• Septic shock has 2 phases:

Early, or warm shock.

late, or cold shock.

Dissociative Shock

Inability of Hemoglobin molecule to give up the oxygen to tissues.

Etiology: Carbon Monoxide poisoning, methemoglobinemia.

Management-General

Goal: increase oxygen delivery and decrease oxygen demand: For all children: ○ A,B,C,… ○ Oxygen ○ Fluid ○ Temperature control ○ Correct metabolic abnormalities

Depending on suspected cause: ○ Antibiotics ○ Inotropes ○ Mechanical Ventilation ○ ……..

Management-General

• Airway

– If not protected or unable to be maintained, intubate.

• Breathing

– Always give 100% oxygen to start

– Saturation monitor

• Circulation

– Establish IV access rapidly = (IO after 90sec/3attempts).

– CR monitor and frequent BP

Coma

Definition:

An unrousable state in which the patient shows no meaningful response to environmental stimuli.

Etiologies

Coma is caused by dysfunction of the cerebral hemispheres (bilaterally), the brainstem, or both.

• Local CNS causes.

• Systemic causes.

• Drugs and Toxins.

• Psychological problems.

Etiologies cont.

Local CNS causes:

– Head Trauma:

• Epidural hematoma, subdural hematoma.

– Vascular:

• Hemorrhage, thrombosis, embolism.

– Epilepsy.

– Infection: Meningitis, Encephalitis.

– Brain Tumors.

Etiologies cont.

Systemic causes:

– Metabolic disorders:

• Hypoglycemia, urea cycle disorders, organic acidemia.

– Renal disease.

– Hepatic failure.

– Severe systemic sepsis.

– Electrolytes disturbances.

– Stroke.

Glasgow Coma Scale (GCS)

BEST EYE

opening

BEST VERBAL

response

BEST MOTOR

response

Spontaneous 4 Oriented 5 Obey commands 6

To verbal stimuli 3 Confused 4 Localize pain 5

To pain 2 Inappropriate words 3 Normal flexion (withdrawal) 4

None 1 Nonspecific sounds 2 Abnormal flexion (Decorticate) 3

None 1 Extension

(Decerebrate ) 2

None 1

Modified GCS for infants

BEST EYE

opening

BEST VERBAL

response

BEST MOTOR

response

Spontaneous 4 Coos, babbles 5 Spontaneous movements 6

To speech 3 Irritable, cries 4 Withdraws to touch 5

To pain 2 Cries to pain 3 Withdraws to pain 4

None 1 Moans to pain 2 Abnormal flexion (Decorticate) 3

None 1 Abnormal extension (Decerebrate ) 2

None 1

Case 2

A 5-year-old child was brought to the ER unconscious. On examination had decerebrate rigidity, open his eyes only to painful stimulus and he did not responded when his mother shouted his name.

•What is the likely score of this child using modified Glasgow Coma Scale?

Case 2

A 3-year-old child was brought to the ER unconscious. On examination had decerebrate rigidity, open his eyes only to painful stimulus and he did not responded when his mother shouted his name.

•What is the likely score of this child using modified Glasgow Coma Scale?

= 5

DIAGNOSTIC APPROACH

• Glucose. • Na+, K+, Cl-, HCO3, BUN, creatinine. • AST, ALT, PT, PTT. • Blood gases. • Ammonia, lead level, pyruvate, lactate. • Urinalysis, and urine amino and organic acids. • CT, MRI, MRA, angiogram. • CSF analysis. • EEG. • Blood and urine analyses for toxic substances.

Management

• Early management of coma is generally supportive until a definitive diagnosis made.

• Treatment of hypoglycemia, raised ICP, bacterial meningitis may be initiated empirically if there are suggestive clinical features.

Management

• ABCs:

– Intubate if GCS is ≤ 8.

– Stabilize cervical spine.

– Supplement O2.

– IV access.

• Glucose:

– Dextrose 0.25 g/kg after blood glucose is drawn and before the results back… Do NOT delay