INTRODUCTION:
Paediatric shock is one of the important cause of mortality and morbidity worldwide. Shock is defined as inability of cardiovascular system to provide adequate oxygen and nutrients to meet metabolic demands of vital organ. Hypovolemic shock due to acute gastroenteritis is the most common type in paediatric shock followed by septic shock. Cardiogenic and obstructive shock are less common in children. Still they are important because they are very difficult to diagnose in paediatric population.
Mortality due to shock is reduced by early recognition.
Ultrasound has a role in identification of reversible and undifferentiated shock.
OBJECTIVE:
1. To study the bedside ultrasound (POCUS) findings in various types of shock in paediatric emergency room.
2. To compare the clinical signs with USG findings in fluid intolerant state during the shock management.
STUDY DESIGN:
Cross- Sectional study (Prospective descriptive).
STUDY SETTING:
All children admitted in Paediatric ER, Institute of Social Paediatrics, Govt Stanley Medical college with shock in the period June 2018 to May 2019.
METHODOLOGY:
All the patients with shock with the age 29 days of life to 12 years of age with shock were selected for the study . Shock patients with other co morbidities like known congenial heart disease, Chronic kidney disease, chronic liver disease, protein losing conditions causing hypoproteinemia, Severe Acute Malnutrition were excluded from the study. Short History obtained from the guardian regarding the cause of the shock, co morbid illness , previous treatment. Clinical assessment- Rapid cardio pulmonary assessment (PEMC Guidelines) done for the child. Categorization of type and severity of shock were done, followed by USG assessment by POCUS protocol. Parameters analysed were Heart-cardiac contractility, pericardial effusion, IVC- diameter, collapsibility, Aorta- diameter, IVC / aorta ratio, Free fluid in the peritoneal cavity, Free fluid in pleural cavity/pneumothorax and Lung parenchyma-diffuse lung rockets, multiple B profile comet tail artifact. Shock was managed according to PEMC guidelines. Child was reassessed clinically and ultrasonographically after every management. Till recovery from the shock, signs of fluid intolerance and after initiation of ionotrope. Children were followed by me throughout the hospital stay/upto death.
STATISTICAL METHOD:
Data was analysed using R software Version 3.6.1. All demographics, clinical, ultrasound measurements and types of shock were represented as frequency and percentages. The agreement between clinical parameters with the ultrasound parameters for fluid overloaded cases were assessed using Kappa agreement statistics.
RESULTS:
Among 103 cases, 64 cases (62%) were hypovolemic shock, 24 cases (23%) were septic shock, 9 cases (9%) were cardiogenic shock and 6 cases were obstructive shock during the initial assessment. 24 cases showed signs of fluid intolerance during shock management. USG findings 103 shock patients showed the following results: Hypovolemic Shock: Hyperdynamic LV (78.2%), IVC/ AORTA ratio decreased (91%), IVC collapsible (100%), Lungs A profile (100%). Septic
Shock: Hyperdynamic LV (79.2%), IVC/AORTA ratio decreased (87.5%), IVC Collapsibility(100%), Lungs USG A profile(100%). Cardiogenic Shock: Hypodynamic LV (100%), IVC/ AORTA fullness (100%), IVC non collapsible (100%), Lungs USG B profile (67%). Obstructive Shock: Hyperdynamic LV (100%), RV Strain (84%), RV diastolic collapse (16%), pericardial effusion (16%). Lungs USG showed absent sliding sign / bar code sign in M mode (68%), loculated effusion (16%).
CONCLUSION:
USG findings in Hypovolemic & septic shock are similar in initial assessment. USG doesn’t help in differentiating the hypovolemic & septic shock. In obstructive & cardiogenic shock USG findings confirms the diagnosis. In fluid intolerant states during shock correction sudden increase in liver span had almost perfect agreement (0.833) with the increased IVC/Aorta ratio (IVC fullness) and IVC non-collapsibility
