Case History 12 year old boy referred to hospital by his GP. He was found to be febrile & drowsy with a few non-blanching spots. The GP gave a dose of intra-muscular penicillin and sent him into hospital as an emergency.
18:00 hours ED triage
Fever for a day, generally unwell with headache, regular paracetamol during day. No urine output since very early morning. No neck stiffness or vomiting. Temperature not coming down, new rash on back, increasingly drowsy.
Observations: temp 39.5, pulse 148, RR40, Cold hands and feet. Sats 92% in air.
Conscious level is V (AVPU scale). Widespread non- blanching rash on trunk
Nursing actions: probable meningococcal disease, put out emergency call for paediatrics. High-flow oxygen started via facemask. BM done = 6.5.
QUESTIONS ON CASE 8
Q 2 of 10: Has the nurse taken the correct immediate action?
Yes No
CORRECT : Nurse has acted appropriately. Severity of situation has been understood. This is a medical emergency. All patients in septic shock should be given high flow oxygen.
Children with evidence of shock need immediate resuscitation:
Assess airway for patency
Give oxygen to all patients even if oxygen saturations are normal in order to optimise tissue oxygenation
Secure good venous access. The goal of circulatory support in shock is the maintenance of tissue perfusion and oxygenation. Remember in shocked children the intra-osseous route may be the most effective way of giving large volume replacement.
Rapid fluid resuscitation should be initiated. Boluses of 20ml/kg of colloid (preferably 4.5% albumin44) or crystalloid solutions should be given rapidly (over 5-10 minutes) whilst monitoring the clinical response (HR, RR, BP, CRT, O2 sats, urine output, conscious level). If the clinical response is short-lived or absent, and shock does not improve or progresses, large volumes may be required (over 60ml/kg in the first hour).
Bloated appearance due to capillary leak syndrome. Fluids given during volume resuscitation contribute to this at first.
There is evidence from adults that early goal-directed resuscitation of patients with septic shock is associated with an improvement in outcome45.
Hypoglycaemia (<3.3 mmol/l) is common and should be corrected: 5ml/kg 10% dextrose bolus i.v., then check glucose hourly and correct if necessary.
If signs of shock persist after 40-60 ml/kg of fluid resuscitation, there is significant risk of pulmonary oedema, so elective tracheal intubation and mechanical ventilation should be initiated even if there are no signs of respiratory failure3. This will optimise oxygenation, reduce the work of breathing, and improve cardiac function.
Advice to guide further management should be sought early.
Invasive monitoring and central venous access will be required to guide fluid therapy and optimise support.
Inotropic support may be required to optimise tissue perfusion and improve myocardial function.
Dobutamine can be infused centrally or peripherally
Metabolic acidosis is common and impairs myocardial contractility. If pH<7.2 due to base deficit, give half correction NaHCO3 iv.
Volume (ml) to give = (0.3 x weight in kg x base deficit ÷2) of 8.4%NaHCO3 over 20 mins.
In neonates, volume (ml) to give = (0.3 x weight in kg x base deficit) of 4.2% NaHCO3.
Metabolic derangements of calcium, magnesium and potassium are common, and need frequent checking and correction .
In cases of severe bleeding or profound clotting disorder, consider correction of coagulopathy with fresh frozen plasma, platelets and, if fibrinogen is low, cryoprecipitate. Correction of thrombocytopaenia is not generally required, but if uncontrolled haemorrhage from venepuncture sites or mucous membranes occurs despite replacement of clotting factors, platelet transfusion may be required if platelets are below 50,000/mm3.
Remember – Call for senior help early. Sick septic children need experienced doctors. This is not the time to ‘have a go!’
