CCF and shock in children

It may sound very surprising but i need to combine these contrast topics to discuss together. As many a times I come across situations where the treating docs even residents and pediatricians alike have made a common mistake of misunderstanding one as another and created problems for the patients and themselves.

How is it possible?
Shock is a situation caused by disparity between fluid volume and capillary bed manifesting as poor pulse and blood pressure.
CCF or congestive cardiac failure is a condition caused due to increased preload following venous overload or cardiac hypo function.

In late stages both these cases can overlap, as shock can cause cardiac dysfunction and cardiac dysfunction due to CCF can lead to shock.

And thus most patients coming in late stages to emergency room are falsly interpreted as shock or CCF especially when the facility for JVP CVP BP measurements is not available or faulty. ( yes its likely- as BP measurement varies with age size of cuff and the person who is taking BP and there are no clear cut levels in any area or age for lowest normal BP. Also CVP may be difficult due to venous access in shock. The CVP reading change with movements , intervention and position of CVP catheter tip which may require an X-ray to confirm.)

In addition the confusion arises due to possibility of presence of congenital heart disease or carditis in children. if the child had a chronic heart disease, its more likely that the decision fo CCF si very often made, as the baseline hepatomegaly and cardiomegaly as a part of chronic heart failure is wrongly interpreted as acute CCF.

Similarly, as in acute carditis or sepsis, raised JVP the only important clinical sign apart from cardiomegaly, is difficult to examine and interpret especially in infants, the failure of heart is interpreted as shock.

As both these conditions present with common findings at some stage
: Tachycardia, poor or weak pulse and low blood pressure and desaturation.
They are easily confused unless an expert decides from various other clinical markers.

why do we need to discriminate the two: CCF and shock?
Because, the treatment differs.
for CCF the main therapy is volume reduction diuresis and judicious blood transfusion and digoxin. And rarely inotropes.

And in shock its fluid pushes and inotropes.

A wrong judgment will take you in wrong direction with vicious events.


Some basic understandings will help not making this mistake:

Hyponutrition, hypovolemia and shock is a more common entity than fluid overload or CCF in any disease situation. Even empirically patient will be in shock than CCF. Except 2.

CCF is more common in association with sever anemia and congenital hearts in infancy mainly below 6 months age. Please confirm the presence of significant hyper dynamic circulation / chest movements /PH with acute cardiomegaly. No cardiomegaly means no CCF. Severe anemia may be a misunderstanding of poor perfusion, please wait till the Hb report before transfusion.

The most important finding that’s easy to discriminate is liver tenderness and JVP when measured accurately. Shock will never have liver tenderness. Liver tenderness without raised JVP or cardiomegaly is more likely to be hepatitis than CCF. Acute liver tenderness is an important sign of fluid overload especially in managing dehydrations and shock.

Presence of creptations is very important sign provided one gets bilateral symmetrical Velcro crackle in basal interscapular area. If you get asymmetric crepts, its patchy pneumonia and if you get crepts all over chest, its ARDS or pulmonary bleed in shock.

Measurement of CVP is by far the most important and standard criterion to discriminate shock and CCF. This may not be possible easily in many developing countries. But an attempt should always be made to get a CVP line in all cases of suspected shock and CCF. CVP more than 10 is surely CCF and CVP less than 5 is surely shock.

The conditions where shock and CCF coexist more often are cardiomypopathy, massive myocardial infarctions, sepsis with carditis and aortic stenosis and other obstructive lesions of heart. In such cases the management is highly judicious giving adequate to fewer fluids with maintenance of BP to lowest normal to perfuse periphery and judicious use of diuretics with calculated fluid and salt intake. Most care should be taken not to combine diuresis with fluid restriction; and avoiding peripheral inotropes that will do only harm by increasing peripheral resistance however small dose it is.

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read http://www.nhlbi.nih.gov/health/dci/Diseases/hyp/hyp_whatis.html
read aug 2008 IJP symposium septic shock Indian journal of pediatrics


http://drpeds.blogspot.com/ http://funnytrivias.blogspot.com/ Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and KEM HOSPITAL MUMBAI INDIA

http://drpeds.blogspot.com

http://funnytrivias.blogspot.com


Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA