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CASE HISTORY


Action taken :

  1. Immediately given antibiotics and 40 ml/kg albumin.
  2. “Crash call” put out for PICU team.
  3. Full set bloods taken.

Results:
WCC 2.4, Hb 10.5, pl 70.
Glucose 3.8
Na 149, K 3.4, Ca 2.1, Mg 0.4, PO4 1.6, urea 10.9, Creat 121.
HCO3 15, BE -7.
PT 30, APPT 75, INR 2.5.
Taken to PICU. Still shocked after 40ml/kg. Electively intubated and ventilated, Adrenaline started.  Commenced correction of acidosis, K, and Mg.

Extensive purpuric rash developed.

PICU consultant called in to supervise care.

10 month old boy. Taken to GP with h/o sudden onset of fever, vomiting and lethargy for 4 hours. Mother very anxious about child. GP referred child to walk-in clinic at hospital.


History on admission: Feverish and drowsy – sudden onset. 2 episodes of vomiting, 1 soft stool, no rash.


Assessment on admission: Drowsy and pale, dark rings around eyes.
Temp 37.7
CVS: P 181, BP 120/52, CRT 4 secs. Child peripherally shutdown.

RS: RR 32 breathing laboured and child cyanosed.
SaO2 100% in oxygen.
NS: GCS10 then 9, no neck stiffness.

Fine blanching rash on abdo/chest. 1 petechial spot on abdo.


Diagnosis: meningococcal septicaemia


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QUESTIONS ON CASE 5


     Q 9 of 11: Adequate investigations?

YesNo <incorrect

INCORRECT : Yes - full set of bloods taken.
Further Information

Initial laboratory assessment

The tests below should be done on all suspected cases of MD and children who are suspected of having an invasive bacterial infection:

  • Glucose
  • Full blood count
  • Electrolytes and urea
  • Calcium and magnesium ( metabolic derangements are common in septicaemia and may contribute to myocardial dysfunction)
  • Phosphate
  • Clotting studies
  • Venous blood gas to measure base excess
  • Blood culture
  • Throat swab culture
  • Meningococcal PCR whole blood (EDTA specimen) to send to reference laboratory

Parameter Normal range*
Hb 10.5 to 13.5 g/dL
WCC 5.0 to 15.0 (×109)
Platelets 150 to 450 (×109)
Base Excess 0 to -3 mmol/L
pH 7.35 to 7.45
HCO3 22 to 26 mmol/L
PaO2 10 to 13.5kPa or 75 to 100mmHg
PaCO2 4.6 to 6kPa or 34.5 to 45 mmHg
Glucose 3.6-5.2 mmol/L
Urea 2.5 to 6.0 mmol/L
Creatinine 19 to 43 mmol/L
Na 133 to 146 mmol/L
K+ 3.5 to 5.5mmol/l
Mg++ 0.66 to 1.0 mmol/L
Total Calcium 2.17 to 2.44 mmol/L
PO4 1.60-2.90 mmol/l
INR 1
PT 9.9 to 12.5 seconds
APTT 26.0 to 38.0 seconds
TT 9.2 to 15.0 seconds
Fibrinogen 1.7 to 4.0 g/L

*Please note that normal ranges for many variables can differ among hospitals.

Blood gas reports measurement of base excess (BE), which, when negative indicates that there is a base deficit (acidosis).


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