23: 15-year-old female with lethargy and fever

Question 1

Physiology of Shock

Answer 1

• As cells are starved of oxygen and substrate, they can no longer sustain metabolism.
• Eventually, cellular metabolism is no longer able to generate enough energy to power the components of cellular homeostasis, leading to disruption of cell-membrane ionic pumps.
• The cell swells, the cell membrane breaks down, and cell death occurs.

Question 2

Children in shock have excellent compensatory mechanisms to maintain tissue perfusion that include:

Answer 2

• Increased heart rate (tachycardia): Because cardiac output is dependent on both stroke volume and heart rate, the body typically tries to maintain cardiac output when stroke volume decreases by increasing the heart rate.
• Increased systemic vascular resistance (vasoconstriction).
• Increased heart contractility: Resulting in more complete emptying of the ventricles.
• Increased venous tone: Results in more blood return to the heart.
• Increased respiratory rate (tachypnea): The body’s attempt to compensate for the metabolic acidosis caused by decreased oxygen perfusion of the tissues and cells.

Question 3

early shock you will find the following:

Answer 3

• elevated heart and respiratory rates
• peripheral blood vessel constriction (causing cool
• clammy extremities and delayed capillary refill time)
• decreased peripheral pulses (due to vasoconstriction and decreased stroke volume).

Question 4

types of Shock: Distributive

Answer 4

—Includes neurogenic and anaphylactic;
—intravascular hypovolemia caused by:
»Vasodilation
»Increased capillary permeability
»Third-space fluid losses

Question 5

types of Shock: Hypovolemic

Answer 5

• Most common type of shock worldwide.

- Results from inadequate fluid intake to compensate for fluid output (e.g., vomiting, diarrhea, hemorrhage.

Question 6

types of Shock: Cardiogenic

Answer 6

Rare in children, but may be associated with the following conditions:

• -Severe congenital heart disease
• -Dysrhythmias
• -Cardiomyopathy
• -Tamponade

Question 7

types of Shock: Septic

Answer 7

–Results when infectious organisms release toxins that affect fluid distribution and cardiac output.
–Can result from bacterial, viral, or-in immunocompromised patients-fungal infections.
–Patients in septic shock typically require repeated boluses of fluid. They may also need medications (epinephrine, norepinephrine or dopamine) to enhance cardiac contractility and to vasoconstrict the vessels.
–It is important to realize that patients in septic shock may present initially as compensated or “warm” shock, with the following findings:
»Warm extremities
»Bounding pulses
»Tachycardia
»Tachypnea
»Adequate urination
»Mild metabolic acidosis

Question 8

Physical Exam Findings in Bacterial Meningitis: only 50% in kids

Answer 8

Neck stiffness (nuchal rigidity)
57-92% of patients

Fever
66-100%

Altered mental status
44-96%

Kernig’s or Brudzinski’s sign
61%

Question 9

Meningococcal dz Risk Factors

Answer 9

• Persons living in close accommodations (students in dormitories, military recruits in boot camp)
• Complement deficiency
• Anatomic or functional asplenia

Question 10

Meningococcal Transmission

Answer 10

• -The disease is transmitted through respiratory droplets and requires close person-to-person contact with an infected individual.
• -The incubation period is 1-10 days

Question 11

Guidelines for Meningococcal Prophylaxis: Close contacts warrant prophylaxis with antibiotics.

Answer 11

• -In adults, ciprofloxacin is the drug of choice.
• -Rifampin, ceftriaxone, and azithromycin are alternatives.
• -Neither rifampin nor ciprofloxacin are recommended for pregnant women.
• -In children (< 18 years old), either oral rifampin or intramuscular ceftriaxone may be used for prophylaxis.

Question 12

Meningococcal Vaccines

Answer 12

MCV4 (quadrivalent meningococcal conjugate vaccine; Menactra and Menveo)
–MCV4 includes serotypes A,C,W and Y. It is given intramuscularly during the routine preadolescent immunization visit (at 11-12 years).
–A booster dose should be given at age 16.
–For high risk populations, MCV4 is indicated as early as 2 months. (See the expert for more detail.)
MenB (serogroup B meningococcal vaccine; Trumenba and Bexsero)
–MenB includes serotype B and is given as one dose at age 16 years.

Question 13

Assessing Circulation

Answer 13

Heart rate is a very sensitive measure of volume status. Tachycardia is the first and most subtle sign of possible inadequate perfusion. It is the most commonly missed finding in patients who have been sent home and return with serious illness.

Question 14

Patients presenting to the ED with fever and a rash must be started on antibiotics as soon as possible. In most instances, ED physicians will start a patient on:

Answer 14

• -Ceftriaxone (to cover gram-negative organisms such as N. meningitidis, as well as gram-positive organisms such as Staph aureus, group A Strep and Strep pneumoniae).
• -Vancomycin (to cover methicillin-resistant Staphylococcus aureus, or MRSA)
• -In endemic areas, doxycycline may be started to cover Rocky Mountain spotted fever.

Question 15

Once a definitive diagnosis of meningococcal disease is made

Answer 15

• one can switch to penicillin G and successfully eradicate the organism from the blood and CSF.
• However, penicillin does not eliminate the carrier state. Therefore, at the end of the penicillin therapy, the patient will need to be treated with either rifampin (children or young adults) or ciprofloxacin (adults).
• Alternatively, a patient can be treated 5 to 7 days with ceftriaxone, which also eliminates the carrier state.

Question 16

Maintaining perfusion overrides all other considerations in managing shock

Answer 16

Intravascular volume replacement is the priority. Fluid replacement should be performed with isotonic solutions (e.g., normal saline), not with hypotonic fluids, and the rate of infusion should be as fast as possible.

Question 17

The ideal approach to vascular access in managing a patient in shock

Answer 17

is to place the largest bore catheter possible - in the largest, most accessible vein. Peripheral venous access is always the first attempt.

Question 18

perfusion takes precedence in fluid management

Answer 18

adequate perfusion will be reflected in clinical parameters (HR, BP, urine output) before it is reflected in BUN/creatinine

Question 19

Differential Diagnosis of Fever and Petechiae

Answer 19

• meningococcal sepsis
• toxic shock syndrome
• RMSF
• bacterial endocarditis

Question 20

A 6-year-old boy presents to the ED with three days of diffuse muscle aches and occasional chills. Today, he had a headache and abdominal pain. He reports that he does not feel hungry because he feels sick to his stomach. He denies recent cough, congestion, sore throat, joint pains, or sick contacts. His vitals are: T 101.3 F, BP 108/71 mmHg, P 110 bpm, R 28 bpm, O2 sat 100% on RA. On physical exam, you notice blanching, erythematous macules on his ankles and several petechiae on his wrists. Upon questioning, his mother says that the spots on his wrists previously looked like the spots on his ankles. His neck is supple and there is no hepatosplenomegaly or lymphadenopathy. He reports no sick contacts, but recently visited his cousins in North Carolina. What is the best next step in management?

Answer 20

Admit the patient, obtain CBC, blood and CSF cultures, then give loading doses of doxycycline 2.2 mg/kg and ceftriaxone 100 mg/kg/day

Question 21

The mother of a 5-year-old boy calls your office asking if she should take her son to the emergency room or wait another day. She states that her son suddenly developed a “high fever” and is extremely tired. When you ask about her son’s behavior, she states that he also seems very confused. She also noticed he had developed reddish-purplish spots on his extremities. What is the next best step in management of this patient?

Answer 21

This patient is exhibiting signs of sepsis, more specifically, of meningococcemia. Although it is important to replenish this patient’s fluids and control his fever, it should not be done in an outpatient setting. This is a medical emergency! Sepsis can lead to altered mental status. Signs and symptoms of sepsis include: fever, nausea, vomiting, diarrhea, apnea/dyspnea, oliguria, pallor, tachypnea, tachycardia, lethargy, irritability, petechiae, purpura, tremors, and seizures.

Question 22

A previously healthy 14-year-old female presents to the ED with a one-day history of fever and altered mental status. Vital signs on presentation include: BP 115/70 mmHg, HR 145 bpm, RR 42 bpm, temp 39.7 C, oxygen sat 93%. Physical exam reveals nuchal rigidity, cool extremities, 1+ distal pulses, diffuse petechial rash, and capillary refill > 2 seconds. What is the important first step in management?

Answer 22

This patient is in septic shock due to meningococcal infection and should immediately be started on IV fluids in order to maintain perfusion to vital organ systems. Although this patient has a normal blood pressure, other vital signs and physical examination point to shock (HR and RR are both significantly elevated), which first and foremost requires fluid resuscitation.

Starting antibiotic therapy is the second step in management after hemodynamic stabilization. While antibiotics should be started as soon as possible, fluid resuscitation is still the classic “next best step” choice when presented with a patient in shock.

Question 23

An 11-month-old boy is brought to the ED by ambulance. His father called 911 after the patient’s eyes deviated to the left as his arms and legs were twitching. During this time he was unresponsive. He has had a tactile fever for three days, and parents mention that he has not been as playful as usual during this time as well. His parents have not had him vaccinated due to personal beliefs. In the ED his vital signs are T 39.1°C, HR 155 bpm, RR 28 bpm, BP 100/65 mmHg, O2 100% (on RA). He does not cry but whimpers during most of your physical exam (including when you look in his ears). You order a CBC and metabolic panel, which are significant for a leukocytosis with a left shift and mild acidosis. Urinalysis and blood/urine cultures are pending. Which of the following additional studies would you obtain?

Answer 23

n a young child with fever and altered level of consciousness we should always have a high suspicion for meningitis. This patient’s parents expressed concerns about his behavior at home before his seizure, and his mental status during your examination is not normal. While very few patients presenting with febrile seizure actually have meningitis, this patient’s lack of immunizations put him at increased risk. Furthermore, clinical signs of meningitis in patients under 12 months of age can be very subtle, and so a high level of suspicion is important. A lumbar puncture will help rule in or out meningitis and guide treatment. Note that in some cases the clinician will request a head CT prior to performing a lumbar puncture if there are concerns about increased intracranial pressure. A head CT in itself may not be helpful in the evaluation of a patient with a seizure, although it may be useful in cases where trauma is suspected, or to look for calcifications (such as with cytomegalovirus infection or tuberous sclerosis).