18:15 hours paediatric registrar and SHO
History taken as above; rash noted to be purpuric.
Initial examination (in oxygen): airway clear, good saturations, equal breath sounds, no crepitations. Heart rate fast at 143, capillary refill time 6 seconds at feet. Heart sounds: gallop rhythm. BP 114/72. Rash is spreading, now on legs as well. Responding to voice, no neck stiffness, equal pupils. Blood gas taken to assess the degree of metabolic acidosis: pH = 7.2, BE= - 9.
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 5 of 10: Correct diagnosis?
Yes No
CORRECT : There are at least 7 signs of shock: tachycardia with gallop rhythm, tachypnoea, prolonged CRP, reduced urine output, drowsiness, hypoxia (on admission), acidosis.
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
