Two hours after admission:
P178, BP 112/60 RR 46.
Increasing rash, drowsy, some response to parents.
No urine output.
Results:
WCC 3.2, INR 2.2,Urea 8.3.
Hb 9.5, Pl 60, Na 132 K 3 Urea 8.3 Creatinine 100
Chest X-ray shows pulmonary oedema.
Frusemide given and fluids slowed down. The child has had a total of 80mls/kg by now.
SHO review: very fast tachycardia, ? need blood gas, ? needs LP.
Six hours after admission:
HR 194, not recognising parents. Doctor reviewed child, advised that Mannitol infusion be considered if further decrease CNS.
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.
QUESTIONS ON CASE 3
Q 9 of 14: After >40ml/kg fluids, were there persistent signs of shock?
YesNo
INCORRECT : Yes -- tachycardia, tachypnoea, no urine output, depressed conscious level, advancing rash, low white cell count.
Septicaemia will lead to shock and multiorgan failure. Shock is a clinical diagnosis. The signs are a result of circulatory failure. The underlying pathophysiology of septicaemia and the capillary leak syndrome leading to these signs are briefly summarised in the pathophysiology section.
A child in early shock may still be alert and have a normal blood pressure. Child lucid despite advancing septicaemia
The early signs of shock include:
Tachycardia
Cool peripheries (CRT>4 seconds) or toe-core temperature gap of >3 degrees
Pallor, mottling
Decreased urine output (<1ml/kg/hr)
Tachypnoea – secondary to acidosis and hypoxia
(In patients with meningococcal disease, signs of shock will usually co-exist with symptoms of septicaemia.)
As shock progresses further signs develop:
Metabolic acidosis with base deficit worse than -5
Hypoxia: PaO2 <10kPa in air or saturation < 95% in air
Increasing tachypnoea, tachycardia and gallop rhythm
