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CASE HISTORY
2.5 year old boy admitted with purpura and fever.
Paediatric assessment:
Temp 39.3, Pulse 134, RR 40, CRT 6 seconds, BP unrecordable, femoral pulses present but weak.
Cyanosed, Saturation 75% in air. Widespread creps.
GCS 9/15, Neck stiffness+
Purpuric rash on chest.
Bloods sent for FBC, clotting, U&E, and culture
Diagnosis:Meningococcal meningitis.
Treatment:Antibiotics intravenously.
Fluids 40 ml/kg colloid in 2 boluses and 10 ml/kg crystalloid over 1 hour, then maintenance fluids.
Some improvement of CRT so left on the ward.
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QUESTIONS ON CASE 3
 
Q 8 of 14: Organ failure?
Yes  No
CORRECT
: Yes, circulatory failure, renal dysfunction, coagulopathy.
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Further Information
Specific organ dysfunction in shock
Respiratory failure
(arterial PO 2 <10kPa in air or PCO 2 >6)
Common in shock. Capillary leak into lung parenchyma  acute pulmonary oedema. Clinically: tachypnoea, chest wall retraction, hypoxia. |
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Metabolic derangement
Septicaemia causes profound acidosis and derangements in metabolism, which may affect myocardial function and need correcting. Hypoglycaemia is common. Hypokalaemia, hypocalcaemia, hypomagnesaemia and hypophosphataemia all occur. |
Myocardial failure
Depressed myocardial function is multifactorial, including endotoxin, cytokines, multiple metabolic derangements, hypoxia, and hypovolaemia. Clinically: tachycardia, gallop rhythm, cool peripheries and eventually hypotension.
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Coagulopathy
(purpuric rash)
Coagulopathy occurs early in patients with septicaemia. The laboratory findings of disseminated intravascular coagulation (DIC) are common in such patients. Coagulopathy is generally associated with the presence of a purpuric rash, but significant coagulopathy may infrequently occur in the absence of purpura. |
Renal failure
Little or no urine output (<1ml/kg/hour) is a very early sign in septic shock, initially due to hypovolaemia. If shock persists then renal failure may occur. Serum creatinine  2 times upper limit of normal for age or 2-fold increase in baseline creatinine indicates renal dysfunction. |
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