Know the different types of shock
Know the different types of shock
ED nurses should be familiar with the many causes of shock in childhood, says Mary Fran Hazinski, RN, MSN, FAAN, clinical specialist in the division of trauma at Vanderbilt University and Children's Hospital in Nashville, TN. "It's important to determine the type of shock so you can correct it and know how to begin therapy," she notes. Here are types of shock with assessment and treatment tips for each:
Hypovolemic shock. Hypovolemia is the most common cause of shock in infants and children. "In children, typically it results from dehydration," says Richard Orr, MD, FAAP, associate director of the pediatric ICU and medical director of pediatric transport at Children's Hospital in Pittsburgh, PA. "Dehydration usually results from gastroenteritis, diabetic ketoacidosis, or vomiting and diarrhea, and requires urgent fluid therapy."
Hypovolemic shock can also be caused by hemorrhage in trauma patients, says Orr. Because signs of hemorrhage can be very subtle in children with blunt trauma, one must always look for evidence of abdominal bleeding in a trauma patient who has shock and no visible signs of injury, he advises.
To differentiate hypovolemic shock from other forms of shock, one should examine the abdomen to determine whether the liver edge is palpable, Orr advises. "In hypovolemic shock, the intravascular volume is depleted and the patient should not be showing signs of right heart failure," he says.
In this instance, the caregiver should be very aggressive in repleting the fluid deficit, Orr says. "However, once the liver edge becomes palpable, one should begin inotropic agents as part of the therapy to improve myocardial function," he notes.
Cardiogenic shock. This can result from a cardiomyopathy, myocarditis or severe congestive heart failure. "This usually requires careful titration of fluid therapy as well as inotropic support and manipulation of systemic vascular resistance," notes Orr.
Septic shock. Septic shock may not be obvious in its early phases, but don't underestimate the severity of the condition, Orr advises. "It's necessary to treat the infection, support myocardial function with inotropic therapy, and in some cases correct excessive vasodilation," he says.
With septic shock, there is maldistribution of blood flow despite an often high cardiac output, says Hazinski. "Septic shock is usually initiated by an infection, although less than half of patients ever have positive cultures," she adds. "But the infection and the toxins it stimulates, and the mediators it activates, can lead to vasodilation, capillary leak, and maldistribution of blood flow."
Anaphylaxis. The history is crucial in diagnosing anaphylactic shock and a prodromal period is usually absent, says Orr. "The patient must come in contact with an anaphylatoxin which causes a release of systemic mediators that cause bronchospasm, laryngospasm, and systemic hypotension, usually within 15 minutes of the exposure," he adds. Common anaphylatoxins in children are bee stings, peanut butter, and antibiotics.
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