ŞOK BULGULARI OLAN ÇOCUĞA YAKLAŞIM Prof. Dr. Dinçer Yıldızdaş Çukurova Üniversitesi Tıp Fakültesi Çocuk Yoğun Bakım Bilim Dalı

ALİ’NİN ŞOK BULGULARINI KİM TEDAVİ EDEBİLECEK? 2

Olgu Ali Dönmez 14 aylık erkek hasta Üç gün önce başlayan kusma ve iki gündür günde 10-15 kez olan ishali olması nedeniyle çocuk acil polikliniğine getirildi 3

Olgu Ateş: 36.5 °C Genel durumu kötü, ağrılı uyaranlara yanıt vermiyor Nabız : 186/dk SS : 52/dk SaO2 : % 96 TA : 45/22 mmHg Genel durumu kötü, ağrılı uyaranlara yanıt vermiyor Ekstremite soğuk, KDZ:7 sn ve alacalı görüntüsü mevcut Takipneik, taşikardik Hem santral hem de periferal nabazanlar alınmıyor Kan gazı;% 60 oksijen alırken pH : 7.12 pCO2 : 22 pO2: 145 HCO3 : 10.4 BE: - 22 4

Soru Şok’un tanımını yapabilirmisiniz? 5

Beklenen Yanıt Dokuların gereksinimi olan maddelerin ve oksijenin karşılanamaması sonucu ortaya çıkan ve doku perfüzyon bozukluğu ile seyreden akut bir durumdur

Soru Şok tablosu acil bir müdahale gerektiren bir durum mudur? 7

Beklenen Yanıt EVET 8

Beklenen Yanıt Hayati organların metabolik gereksinimlerinin karşılanması için yeterli perfüzyon olmaması Yeterli oksijen ulaşmaması Anerobik metabolizma ve laktik asidoz Kardiovasküler kolaps veya multiorgan yetmezliği ile ölüm

Soru Kaç tip şok vardır? 10

Beklenen Yanıt Hipovolemik Distribütif (septik, nörojenik, anaflaktik vb) Kardiyojenik Obstruktif

Soru Kan basıncını etkileyen kardiyovasküler değişkenler nelerdir? 12

Beklenen Yanıt Ön yük Miyokardın kasılması Atım hacmi Ard yük Kalp hızı Kalp debisi Sistemik vasküler direnç Kan Basıncı Slide 10: Cardiovascular Variables Affecting Systemic Perfusion This graphic illustrates the relationship of cardiovascular variables that affect cardiac output and systemic perfusion. Note that one goal of PALS is to support cardiac output (the amount of blood delivered to the tissues each minute) that is adequate to meet tissue oxygen demand. Although many variables influence cardiac output and oxygen delivery, the only variables readily measured in the clinical setting are the child’s heart rate and blood pressure. Note that blood pressure can be maintained despite a fall in cardiac output if systemic vascular resistance increases. This explains how children can have a normal blood pressure despite the presence of shock (compensated shock). If cardiac output is inadequate, we attempt to improve it through support of an optimal heart rate and stroke volume. Stroke volume is supported through manipulation of cardiac preload, contractility, and afterload. 13

Soru Şok=Hipotansiyon mudur? 14

Beklenen Yanıt Şoka Hemodinamik Cevap 140 100 60 20 Vasküler direnç Kontrolün yüzdesi Slide 11: Hemodynamic Response to Shock in Infants and Children This figure illustrates typical changes in heart rate, blood pressure, and cardiac output as the child moves from compensated to decompensated (ie, hypovolemic to hypotensive) shock. Note that tachycardia without hypotension is present in compensated shock. Blood pressure is initially maintained through an increase in systemic vascular resistance. As cardiac output falls further, blood pressure begins to fall, and shock is characterized as decompensated shock. Kalp debisi Kan basıncı Kompanse şok Dekompanse şok

Soru Şoktaki hastada hangi bulguları değerlendirirsiniz? 16

Beklenen Yanıt Fizik Muayene: Dolaşım Kardiyovasküler fonksiyon Kalp hızı Nabız, kapiller geri dolum zamanı Kan basıncı Organ Etkilenimi/Perfüzyon Beyin Deri Böbrekler Slide 13: Physical Examination of the Circulation Cardiovascular assessment begins with an evaluation of the child’s responsiveness—if the child is unresponsive, urgent intervention is required. Then you begin direct assessment of the cardiovascular system, including evaluation of heart rate, quality of proximal and distal pulses, and blood pressure. Indirect assessment of the cardiovascular system is discussed later and includes evaluation of signs of end-organ function to evaluate end-organ perfusion. End-organ function includes function of the brain, skin, and kidneys. You will evaluate indirect signs of brain and skin perfusion during the cardiovascular assessment. A compromise in end-organ function may indicate that cardiac output and end-organ perfusion are inadequate.

Soru Bilinç durumunu hangi nörolojik skala ile takip edersiniz? 18

Bilinç Durumunu Değerlendir Beklenen Yanıt Bilinç Durumunu Değerlendir U — Uyanıklık S — Sese yanıt verme A — Ağrıya yanıt verme Y — Yanıtsızlık Slide 15: Physical Examination of the Circulation—Evaluation of Responsiveness Indirect assessment: Evaluation of responsiveness may provide important information about cerebral perfusion. The AVPU assessment is used to describe the level of responsiveness as a simple, reproducible method of evaluating and tracking the child’s level of consciousness (reflecting brain perfusion). The child’s responsiveness and level of consciousness will deteriorate as cerebral perfusion deteriorates. Note: If the level of consciousness/responsiveness has deteriorated, the healthcare provider should be prepared to rule out primary neurologic disease or injury but should also suspect a compromise in cardiorespiratory function.

Soru Şoktaki bir hastada en erken beklenen yanıt hangisidir? 20

Çocuklardaki Kalp Hızları Bebeklerde 85 220 300 Normal Sinüs Taşikardisi SVT Çocuk Slide 16: Typical Ranges of Heart Rates in Children The heart rate in infants and children normally varies with age and activity. The “normal” range of heart rate decreases as the child ages. Heart rate must be evaluated in the context of the patient’s clinical condition. Heart rate increases with fever, anxiety, pain, or shock. A healthy, screaming 6-year-old child may have a heart rate of 130 bpm. The same heart rate of 130 bpm in a quiet 6-year-old child may be evidence of shock. Increased heart rate (tachycardia) may be a nonspecific sign of cardiorespiratory distress. Heart rate ranges for normal sinus rhythm, sinus tachycardia, and supraventricular tachycardia (SVT) overlap, as depicted in the slide. The diagnosis of SVT should always be considered when the heart rate is more than 220 bpm in an infant and more than 180 bpm in a child. 60 180 200 Normal Sinüs Taşikardisi SVT

Soru Şoktaki hastada hangi deri perfüzyon bulgularını değerlendirirsiniz? 22

Deri Perfüzyonun Değerlendirilmesi Beklenen Yanıt Deri Perfüzyonun Değerlendirilmesi Ekstremitelerin ısısı Kapiller geri dolum zamanı Renk Pembe Soluk Mor Alacalı Slide 17: Physical Examination of the Circulation—Evaluation of Skin Perfusion Indirect assessment: Evaluation of skin perfusion may provide important information about cardiac output. Skin perfusion may be compromised early in some forms of shock (eg, hypovolemic and cardiogenic shock) that result in redistribution of blood flow away from the skin and toward vital organs (brain, heart). Pulses: Peripheral pulses may be diminished if stroke volume is decreased or peripheral vasoconstriction is present. Temperature: Cool extremities suggest inadequate cardiac output or cold ambient temperature. Capillary refill: Normal capillary refill time should be less than 2 seconds if the ambient temperature is warm. Color can change with changes in perfusion/oxygen delivery: Pink color of mucous membranes indicates normal perfusion. Pale color may indicate ischemia, anemia, or cold environment. Blue color (cyanosis) indicates hypoxemia or inadequate perfusion with pooling of blood flow or increased oxygen extraction in the skin. Mottled color may be caused by a combination of the above. With distributive shock (eg, septic shock) skin perfusion may be normal or adequate.

Soru Hastamızın kapiller geri-dolum zamanı kaç idi? 24

Beklenen Yanıt Slide 15: Physical Examination of the Circulation—Evaluation of Responsiveness Indirect assessment: Evaluation of responsiveness may provide important information about cerebral perfusion. The AVPU assessment is used to describe the level of responsiveness as a simple, reproducible method of evaluating and tracking the child’s level of consciousness (reflecting brain perfusion). The child’s responsiveness and level of consciousness will deteriorate as cerebral perfusion deteriorates. Note: If the level of consciousness/responsiveness has deteriorated, the healthcare provider should be prepared to rule out primary neurologic disease or injury but should also suspect a compromise in cardiorespiratory function. 25

Beklenen Yanıt Slide 15: Physical Examination of the Circulation—Evaluation of Responsiveness Indirect assessment: Evaluation of responsiveness may provide important information about cerebral perfusion. The AVPU assessment is used to describe the level of responsiveness as a simple, reproducible method of evaluating and tracking the child’s level of consciousness (reflecting brain perfusion). The child’s responsiveness and level of consciousness will deteriorate as cerebral perfusion deteriorates. Note: If the level of consciousness/responsiveness has deteriorated, the healthcare provider should be prepared to rule out primary neurologic disease or injury but should also suspect a compromise in cardiorespiratory function. 7 sn 26

Soru Santral ve periferal nabazanlarımız nelerdir? 27

Beklenen Yanıt Slide 18: Palpation of Central and Distal Pulses Evaluation of pulses and distal perfusion is part of the direct cardiovascular assessment. Palpation of central and peripheral pulses provides important information for the cardiovascular examination: Palpation of pulses can be used to evaluate heart rate and some indirect evidence of stroke volume and systemic vascular resistance. Pulse quality reflects the adequacy of peripheral perfusion. Weak or absent pulses may indicate poor stroke volume, increased systemic vascular resistance, or both. Loss of perfusion in hands and feet often precedes hypotension and critical loss of vital organ perfusion in shock. Hypotension often develops before loss of central pulses.

Soru Hastanın böbrek fonksiyonunu değerlendirirken mesanedeki ilk ölçülen idrar miktarı anlamlı mıdır? 29

Beklenen Yanıt Organ Etkilenimi Böbrekler İdrar Çıkışı Normal: 1-3 ml/kg/saat (bebeklerde) 0.5- 3 ml/kg/saat (daha büyük çocuk) Mesanede bulunan ilk idrar miktarının ölçümü anlamlı değildir Slide 22: Evaluation of End-Organ Perfusion—Kidneys Normal urine output is expected if the infant or child is well hydrated and well perfused with good renal function. A decrease in “normal” urine output may indicate inadequate renal perfusion (caused by dehydration or low cardiac output) or a compromise in renal function. Urine output decreases as renal perfusion decreases. When a bladder catheter is first inserted, the initial measurement of urine output is often not helpful because the volume of urine in the bladder accumulated over an unknown period of time. Once a urinary catheter is inserted, you can evaluate urine volume on an hourly basis.

Soru Çocuklarda yaşa göre en düşük sistolik kan basınç değerleri nelerdir? 31

Beklenen Yanıt En Düşük Sistolik Kan Basınçları Yaş En düşük sistolik kan basıncı (%5) 0-1 ay 60 mm Hg >1 ay ile 1 yaş 70 mm Hg 1 ile 10 yaş 70 mm Hg + 2 ´ yaş (yıl)] >10 yaş 90 mm Hg Slide 20: Physical Examination of the Circulation—Estimate of Minimum Systolic Blood Pressure Ranges in Infants and Children Lower-limit (5th percentile) systolic pressures are estimated in children 1 to 10 years of age, using the following formula: 70 mm Hg + (2 x age in years) = 5th percentile systolic BP Note that children older than 10 years should have a systolic blood pressure of at least 90 mm Hg. Blood pressures lower than the recommended ranges are usually inadequate. Remember: A child may demonstrate signs of shock despite a “normal” blood pressure (this is compensated shock). The presence of a blood pressure lower than the minimum systolic blood pressure range for the child’s age indicates hypotension and the presence of decompensated shock.

Soru Şoku bulgularını genel olarak kaç tipe ayırıyoruz? 33

Beklenen Yanıt KOMPANSE ŞOK DEKOMPANSE ŞOK

Soru Kompanse şokun bulguları nelerdir? 35

Kompanse Şok Taşikardi Soğuk deri veya sıcak deri Kapiller geri dolum zamanının uzaması Santral nabazanlarla karşilaştırıldığında zayıf periferal nabazanlar

Soru Dekompanse şokun bulguları nelerdir? 37

Beklenen Yanıt Bilinç durumunda değişme: Huzursuzluk, konfüzyon, stupor, koma Taşipne Santral nabazanlarda zayıflama Metabolik asidoz Oligoüri Hipotansiyon   

Soru Bizim hastamız kompanse şok mu yoksa dekompanse şok mu? 39

Olgu Ateş: 36.5 °C Genel durumu kötü, ağrılı uyaranlara yanıt vermiyor Nabız : 186/dk SS : 52/dk SaO2 : % 96 TA : 45/22 mmHg Genel durumu kötü, ağrılı uyaranlara yanıt vermiyor Ekstremite soğuk, KDZ:7 sn ve alacalı görüntüsü mevcut Takipneik, taşikardik Hem santral hem de periferal nabazanlar alınmıyor Kan gazı;% 60 oksijen alırken pH : 7.12 pCO2 : 22 pO2: 145 HCO3 : 10.4 BE: - 22 40

Olgu Ateş: 36.5 °C Genel durumu kötü, ağrılı uyaranlara yanıt vermiyor Nabız : 186/dk SS : 52/dk SaO2 : % 96 TA : 45/22 mmHg Genel durumu kötü, ağrılı uyaranlara yanıt vermiyor Ekstremite soğuk, KDZ:7 sn ve alacalı görüntüsü mevcut Takipneik, taşikardik Hem santral hem de periferal nabazanlar alınmıyor Kan gazı;% 60 oksijen alırken pH : 7.12 pCO2 : 22 pO2: 145 HCO3 : 10.4 BE: - 22 41

Beklenen Yanıt Dekompanse Şok Slide 15: Physical Examination of the Circulation—Evaluation of Responsiveness Indirect assessment: Evaluation of responsiveness may provide important information about cerebral perfusion. The AVPU assessment is used to describe the level of responsiveness as a simple, reproducible method of evaluating and tracking the child’s level of consciousness (reflecting brain perfusion). The child’s responsiveness and level of consciousness will deteriorate as cerebral perfusion deteriorates. Note: If the level of consciousness/responsiveness has deteriorated, the healthcare provider should be prepared to rule out primary neurologic disease or injury but should also suspect a compromise in cardiorespiratory function. 42

ŞOKUN TEDAVİSİ

Soru Şokun tedavisindeki amaç nedir? 44

Beklenen Yanıt Oksijen dağılımını artırmak ve oksijen tüketimini en aza indirmektir

Oksijen Dağılımı Oksijen dağılımı = KD x CaO2 Kalp debisi (KD) = hız x atım hacmi Atım hacmini etkileyen ön yük, ard yük ve kontraktilite Arteriyel Oksijen içeriği (CaO2) = Hb X SaO2 X 1,34 + (0,003 X PaO2)

Soru O zaman ilk başlangıç tedavimiz ne olmalı? 47

Beklenen Yanıt Havayolu Solunum 100 % oksijen ver Gerekirse entübe et Dolaşım Acil damar yolu aç Monitorize et ve sık TA takibi yap

Soru Şoktaki hasta hangi durumlarda entübe edilmelidir? 49

Beklenen Yanıt MSS deprese ise Havayolu obstrüksiyonu varsa Havayolu reflekslerinin kaybı varsa Kısa zaman içerisinde klinik durumun bozulması bekleniyor ve solunum işi çok artmışsa Mekanik ventilasyon ve/veya PEEP ihtiyacı varsa

Soru Şoktaki hastada şimdi ne yapalım? 51

Damar yolunu aç ve hacim genişletici ver Beklenen Yanıt Kristalloid (SF veya RL) Kolloidler Miyokardiyal yetersizlik yoksa 10-20cc/kg 5-20 dakika içerisinde Miyokardiyal yetersizlik varsa 5-10cc/kg 20 dakika içerisinde Her sıvı öncesi hasta mutlaka değerlendirilir Gerekirse sıvı yüklemesi tekrarlanabilir Mümkünse CVP takibi

Soru Ne zaman intraoessosos girişim düşünmeliyiz ve bu uygulamayı en sık nereden yapmalıyız? 53

Beklenen Yanıt

Beklenen Yanıt

Beklenen Yanıt

Damar yolunu aç ve hacim genişletici ver Kristalloid (SF veya RL) Kolloidler (albumin gibi) Miyokardiyal yetersizlik yoksa 10-20cc/kg 5-20 dakika içerisinde Miyokardiyal yetersizlik varsa 5-10cc/kg 20 dakika içerisinde Her sıvı öncesi hasta mutlaka değerlendirilir Gerekirse sıvı yüklemesi tekrarlanabilir Mümkünse CVP takibi

Soru Şokta hastada bolus sıvı mı yoksa 24 saatlik infüzyon sıvısı mı önemlidir? 58

Pediatrik Septik Şok Mortalitesi 1963-2005 Beklenen Yanıt Pediatrik Septik Şok Mortalitesi 1963-2005 Modern tıbbın geçtiğimiz yıllarda gösterdiği en önemli başarılardan birisi çocuk hastalarda sepsis tedavisinde olmuştur. Fig. 2 Single-center ‘best’ mortality rates (%) from septic shock have decreased with the implementation of aggressive fluid resuscitation in the emergency department: 1963, University of Minnesota – mortality from gram-negative bacteria sepsis in infants and children before modern intensive care medicine became standard [16]; 1985, National Children’sMedical Center – mortality from all-cause infant and pediatric septic shock before aggressive fluid administration became standard [17]; 1997, St Mary’s Hospital – mortality from meningococcus with early albumin resuscitation in community hospital emergency departments [18]; 2004, Kenya – mortality from malarial shock with early albumin resuscitation in the emergency room [19]; 2005, Vietnam – mortality from dengue shock with early administration of isotonic crystalloid or colloid [20–22] Crit Care Med 2006; 34(9 Suppl): S183-90

Sıvı tedavisi ile azalan mortalite Beklenen Yanıt

Soru Sıvı verirken hastada akciğer ödemine gidişi nasıl anlarız? 61

Beklenen Yanıt Akciğer dinleme bulguları Hepatomegali Jugüler venöz dolgunluk Taşikardisi azalmış iken tekrar taşikardisi gelişmeye başlamış ise Slide 15: Physical Examination of the Circulation—Evaluation of Responsiveness Indirect assessment: Evaluation of responsiveness may provide important information about cerebral perfusion. The AVPU assessment is used to describe the level of responsiveness as a simple, reproducible method of evaluating and tracking the child’s level of consciousness (reflecting brain perfusion). The child’s responsiveness and level of consciousness will deteriorate as cerebral perfusion deteriorates. Note: If the level of consciousness/responsiveness has deteriorated, the healthcare provider should be prepared to rule out primary neurologic disease or injury but should also suspect a compromise in cardiorespiratory function. 62

Soru Sıvı olarak kristalloid mi yoksa kolloid mi tercih edelim? 63

Beklenen Yanıt İzotonik kristalloid solüsyonlar; hem ucuz, hem de kolay ulaşılabilir olmaları ve diğerlerine göre etkinlik farkı olmamasından dolayı daha avantajlıdır. Carcillo JA, et al. Crit Care Clin; 2003.

Soru Sıvıya yanıt vermeyen şokta ne yapalım? 65

Beklenen Yanıt İnotroplar Kalp hızını arttırmak Kardiyak outputu arttırmak Kardiyak kontraktiliteyi arttırmak Kardiyak outputu redistrübitize etmek Vasküler direnci düzenlemek

Soru Soğuk şok ile sıcak şokun farkı nedir? 67

Beklenen Yanıt SOĞUK SICAK ŞOK ŞOK Mental durum değişikliği Azalmış idrar çıkışı < 1 ml/kg/saat Hipotansiyon doğrular ancak şart değil Kapiller dolum zamanı > 2-3 sn Kapiller dolum zamanı < 1 sn Azalmış nabızlar Sıçrayıcı nabızlar Soğuk Ekstremiteler Sıcak ekstremiteler SOĞUK ŞOK SICAK ŞOK

Olgu Ali Dönmez 14 aylık erkek hasta Üç gün önce başlayan kusma ve iki gündür günde 10-15 kez olan ishal olması nedeniyle çocuk acil polikliniğine getirildi 69

Olgu Kan gazı;% 60 oksijen alırken pH : 7.12 pCO2 : 22 pO2: 145 Ateş: 36.5 °C Nabız : 186/dk SS : 52/dk SaO2 : % 99 dk TA : 45/22 mmHg Genel durumu kötü, ağrılı uyaranlara yanıt veriyor Ekstremite soğuk, KDZ:7sn ve alacalı görüntüsü mevcut Takipneik, taşikardik Hem santral hem de periferal nabazanlar alınmıyor Kan gazı;% 60 oksijen alırken pH : 7.12 pCO2 : 22 pO2: 145 HCO3 : 10.4 BE: - 22 70

Soru Öyküye göre öncelikle hangi şoku düşünürsünüz? 71

Beklenen Yanıt HİPOVOLEMİK ŞOK Slide 15: Physical Examination of the Circulation—Evaluation of Responsiveness Indirect assessment: Evaluation of responsiveness may provide important information about cerebral perfusion. The AVPU assessment is used to describe the level of responsiveness as a simple, reproducible method of evaluating and tracking the child’s level of consciousness (reflecting brain perfusion). The child’s responsiveness and level of consciousness will deteriorate as cerebral perfusion deteriorates. Note: If the level of consciousness/responsiveness has deteriorated, the healthcare provider should be prepared to rule out primary neurologic disease or injury but should also suspect a compromise in cardiorespiratory function. 72

Soru İlk müdahaleniz ne olur? 73

Beklenen Yanıt ABCDE Slide 15: Physical Examination of the Circulation—Evaluation of Responsiveness Indirect assessment: Evaluation of responsiveness may provide important information about cerebral perfusion. The AVPU assessment is used to describe the level of responsiveness as a simple, reproducible method of evaluating and tracking the child’s level of consciousness (reflecting brain perfusion). The child’s responsiveness and level of consciousness will deteriorate as cerebral perfusion deteriorates. Note: If the level of consciousness/responsiveness has deteriorated, the healthcare provider should be prepared to rule out primary neurologic disease or injury but should also suspect a compromise in cardiorespiratory function. 74

Hastanın tedaviye yanıtı Olgu Hastanın tedaviye yanıtı Entübasyona ve ventilasyona yanıt verdi: Kalp hızı: 180/dk Kan basıncı: 50 mm Hg sistolik, KDZ 7 sn Gövde ve ekstremite siyanotik ve alacalı görüntü Hem santral hem periferik nabızlar alınmıyor Ağrılı uyarana yanıt yok Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s.

Soru Hasta şokta mı? Şokta ise kompanse mi yoksa dekompanse mi? 76

Beklenen Yanıt OLGU Entübasyona ve ventilasyona yanıt verdi: Kalp hızı: 180/dk Kan basıncı: 50 mm Hg sistolik, KDZ 7 sn Gövde ve ekstremite siyanotik ve alacalı görüntü Hem santral hem periferik nabızlar alınmıyor Ağrılı uyarana yanıt yok Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s.

Beklenen Yanıt Dekompanse ŞOK OLGU Entübasyona ve ventilasyona yanıt verdi: Kalp hızı: 180/dk Kan basıncı: 50 mm Hg sistolik, KDZ 7 sn Gövde ve ekstremite siyanotik ve alacalı görüntü Hem santral hem periferik nabızlar alınmıyor Ağrılı uyarana yanıt yok Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s. Dekompanse ŞOK 78

Soru Şimdi ne yapalım? 79

Beklenen Yanıt SIVI VERELİM Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s.

OLGU Kalp hızı: 170/dk , KDZ: 5 sn Kan basıncı: 90 mm Hg sistolik Gövde pembe ve ekstremite uçları siyanotik Santral nabazanlar alınıyor, periferik nabızlar alınmıyor Ağrılı uyarana yanıt veriyor Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s.

Soru Hasta hala Şokta mı? 82

Beklenen Yanıt OLGU Kalp hızı: 170/dk , KDZ: 5 sn Kan basıncı: 90 mm Hg sistolik Gövde pembe ve ekstremite uçları siyanotik Santral nabazanlar alınıyor, periferik nabızlar alınmıyor Ağrılı uyarana yanıt veriyor Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s.

Beklenen Yanıt Kompanse ŞOK OLGU Kalp hızı: 170/dk , KDZ: 5 sn Kan basıncı: 90 mm Hg sistolik Gövde pembe ve ekstremite uçları siyanotik Santral nabazanlar alınıyor, periferik nabızlar alınmıyor Ağrılı uyarana yanıt veriyor Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s. Kompanse ŞOK 84

Soru Şimdi ne yapalım? 85

Beklenen Yanıt SIVI VERELİM Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s.

OLGU Kalp hızı: 120/dk , KDZ: 2 sn Kan basıncı: 100 mm Hg sistolik Gövde ve ekstremite pembe Santral ve Periferik nabızlar alınıyor Ağlamaya başlamış Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s.

Soru Şimdi ne yapalım? 88

Beklenen Yanıt MUTLU SON Slide 31: Case Progression The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00. Clinical signs are as described in the slide. What is the child’s physiologic status now? Answer: Decompensated shock What are your next priorities? Obtain vascular access rapidly if this has not been achieved. Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s.

TEŞEKKÜRLER 90

Normal Kalp Hızları Yenidoğan-3ay 85-205 140 80-160 3ay-2 yaş 100-190 UYANIKKEN ORTALAMA UYKUDA Yenidoğan-3ay 85-205 140 80-160 3ay-2 yaş 100-190 130 75-160 2 yaş-10 yaş 60-140 80 60-90 10 yaş ve üzeri 60-100 75 50-90

Kapiller Geri Dolum Zamanı Slide 19: Evaluation of Capillary Refill These 2 photos of the foot demonstrate a capillary refill time of 10 seconds in a 3-month-old infant in cardiogenic shock with a systolic blood pressure of 90 mm Hg 1 hour before death. To evaluate capillary refill, elevate the extremity above the level of the heart to ensure that arterial (not venous) perfusion is being evaluated. Note: Capillary refill can also be prolonged in cold ambient tempera- tures or hypothermia.