Case 23

Question 1

What are key findings from history in a patient with meningococccemia?

Answer 1

Rash, lethargy, tachypnea, decreased urine output

Question 2

What are key findings from the physical exam in a patient with meningococcemia?

Answer 2

Petechial rash, tachycardia, nuchal rigidity

Question 3

What is on the differential diagnosis for meningococcemia?

Answer 3

Hypoglycemia, poisoning, DKA, CNS tumor, meningitis, renal failure, encephalitis, pneumonia, sepsis.

Question 4

What are key findings from testing for meningococcemia?

Answer 4

Gram stain positive for gram-negative diplococci, consistent with meningococcus.

Question 5

What is the definition of shock?

Answer 5

Inadequate delivery of substrate and oxygen to meet the metabolic needs of tissues. In the pediatric age group, shock is not a blood pressure diagnosis; children can maintain a normal bp until they are in profound shock.

Question 6

Compensatory mechanisms of children in shock:

Answer 6

Children in shock have excellent compensatory mechanisms to maintain tissue perfusion, including:

• Inc. HR (tachycardia): When SV decreases, the body tries to maintain cardiac output by increasing HR.
• Increased systemic vascular resistance (vasoconstriction)
• Increased heart contractility (more complete emptying of the ventricles)
• Increased venous tone (greater 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 7

Types of shock:

Answer 7

1. Hypovolemic
2. Septic
3. Cariogenic
4. Distributive

Question 8

What types of shock are most common in children?

Answer 8

Hypovolemic and septic.

Question 9

Hypovolemic shock:

Answer 9

Inadequate fluid intake to compensate for fluid loss (eg vomiting, diarrhea, hemorrhage)
–Signs and symptoms include: Mental status changes, tachypnea, tachycardia, hypotension, cool extremities, oliguria.(low urine output)

Question 10

Septic shock:

Answer 10

Infectious organisms release toxins that affect fluid distribution and cardiac output. May be bacterial, viral or - in immunocompromised patients - fungal. Patient needs repeated boluses of fluid. May need isotopes to enhance cardiac contractility and vasopressors (epinephrine or dopamine) to raise blood pressure.
–Signs and symptoms: May present initially as compensated or “warm shock” (warm extremities, bounding pulses), tachycardia, tachypnea, adequate urination, mild metabolic acidosis.

Question 11

Cardiogenic shock:

Answer 11

Rare in children; may be associated with severe congenital heart disease, dysrhythmias, cardiomyopathy, or tamponade.
–Signs and symptoms include: Cool extremities, delayed capillary refill (greater than 2 seconds), hypotension, tachypnea, increasing obtundation, decreased urine output.

Question 12

Distributive shock:

Answer 12

Includes neurogenic shock and anaphylactic shock - where vasodilation, increased capillary permeability, and third-space fluid loss results in intravascular hypovolemia.

Question 13

Criteria for recommending immediate medical attention:

Answer 13

• Consider a patient to be dangerously ill if the vital life functions of delivering oxygen and nutrients to end organs are impaired.
• Assess functioning of the brain, skin, kidneys and lungs
• Also determine if there are underlying conditions that place the patient at risk (eg, sickle cell disease, human immunodeficiency virus, neutropenia, diabetes mellitus)

Question 14

When treating a patient in an emergent situation, what do you always start with?

Answer 14

ABCs - it is essential to look first for anything that reduces oxygen and critical nutrients to cells.

Question 15

What does A stand for?

Answer 15

Airway: If patient does not seem to be moving air with breathing, first check the airway and determine if there is an obstruction. May need to:

• Position the neck
• Perform a jaw thrust (if concern about head trauma)

Question 16

What does B stand for?

Answer 16

Breathing: Observe effort and rate of breathing, how the patient’s lung sound, and if they are well oxygenated:

• Look at the chest to determine the respiratory rate.
• Listen to breath sounds for wheezes, rales, rhonchi, diminished breath sounds.
• Use a pulse oximeter to rapidly assess the oxygenation of the patient (may be difficult due to vasoconstriction)

Question 17

What does C stand for?

Answer 17

Circulation

• Tachycardia is first and most subtle sign of possible inadequate perfusion.
• Check capillary refill - a sensitive sign of hypovolemia.

Question 18

In reality, what do the ABCs also include?

Answer 18

D and E (disability and dextrose) (exposure and environment)

Question 19

Disability:

Answer 19

A quick neurological assessment to uncover signs of increased ICP or possible poisoning:

• Assess mental status
• Examine pupils, including their size and reaction to light.
• -Pupillary changes, especially unequal pupils, are a sign of increased ICP.
• -May find a clue to a toxidrome (such as lethargy and pinpoint pupils, suggesting opioid ingestion)

Question 20

Dextrose:

Answer 20

This is a reminder to check for hypoglycemia, a condition that must be diagnosed and treated immediately.

Question 21

Exposure and environment:

Answer 21

Expose and examine all parts of the patient, and keep the patient warm during the evaluation

Question 22

What is on the differential for altered mental status or lethargy in a child?

Answer 22

Meningitis, Sepsis, DKA, Renal failure, Ingestion, CNS tumor, Hypoglycemia, Encephalitis, Pneumonia

Question 23

Meningitis

Answer 23

Fever in child with altered mental status highly suggestive of meningitis. Tachypnea and decreased urine output consistent with associated shock. Hallmark symptoms of meningitis are fever, headache, stiff neck, altered mental status, and photophobia (although many patients present with only two or three of these clinical indicators).

Question 24

Sepsis:

Answer 24

Fever and lethargy are prominent symptoms with sepsis. Tachypnea and decreased urine output are also commonly seen.

Question 25

DKA:

Answer 25

Patients in DKA can present with lethargy and tachypnea. Urine output would be increased, not decreased.

Question 26

Renal failure:

Answer 26

Associated acidosis could lead to tachypnea and lethargy. May be primary or secondary (i.e., due to another etiology)

Question 27

Ingestion:

Answer 27

Overdoses can often cause otherwise unexplained lethargy. Depending on toxin, decreased urine output and tachypnea may be seen.

Question 28

CNS tumor:

Answer 28

Increased ICP due to mass effect from a CNS tumor may lead to lethargy and tachypnea.

Question 29

Hypoglycemia:

Answer 29

Low blood sugar may cause lethargy and altered mental status.

Question 30

Encephalitis:

Answer 30

Often caused by viral infections in children. Presents with altered mental status and fever.

Question 31

Pneumonia:

Answer 31

Fever and tachypnea would be found with pneumonia, but altered mental status would be uncommon unless patient was severely hypoxic.

Question 32

What is on the differential for petechial rash, fever, lethargy and shock in a child?

Answer 32

Meningococcal sepsis, Kawasaki disease, Toxic shock syndrome, Scarlet fever

Question 33

Meningococcal sepsis:

Answer 33

Whenever a patient presents with a fever and petechiae, meningococcal sepsis must always be at the top of the differential diagnosis - even if the patient otherwise looks well. A blood culture must be collected and antibiotics given until the disease can be definitively ruled out. The fatality rate in all ages is 10 percent, 25 percent in adolescents. Sequelae, occurring in 11-19 percent of patients, including hearing loss, neurologic disability, digit or limb amputations and skin scarring.

Question 34

Kawasaki disease:

Answer 34

Fever and rash are associated signs. Mucocutaneous lesions include a “strawberry” tongue and dry, red, cracked lips. There is diffuse erythema of the oral cavity and erythema and/or edema of hands/feet and a polymorphic truncal rash.

Question 35

Toxic shock syndrome:

Answer 35

Cause of fever and a sunburn-looking rash that might feel rough to the touch (like sandpaper).

Question 36

Scarlet fever:

Answer 36

This starts as a finely punctate pink-scarlet exanthem that appears on the upper trunk 12-48 hours after onset of fever. As rash spreads to the extremities, it becomes confluent and feels like sandpaper. Linear petechiae (Pastia’s sign) are evident in body folds. Pharynx is beefy red and the tongue is initially white and rough (strawberry tongue), later becoming bright red.

Question 37

CBC with differential and platelets, blood/urine culture, and gram stain:

Answer 37

These are needed to rule sepsis in or out as soon as possible. Also, blood and urine cultures must be obtained before starting antibiotics.

Question 38

Initial emergency management of shock:

Answer 38

• Intravascular volume replacement is the priority, even when there is a risk of increased ICP.
• In most patients, a fluid bolus of 20 cc/kg NS should be given rapidly via IV or intraosseous line.
• Replace fluid volume replacement with isotonic saline, not hypotonic.
• If patient continues to have poor perfusion and shock after fluid resuscitation, may need vasoactive agents.

Question 39

Indications for intraosseous (IO) access:

Answer 39

In an emergency, if a peripheral IV line cannot be placed within 90 seconds, an IO line (via a needle inserted into the marrow cavity of a long bone) should be placed. This provides fast and easy access for any fluid. Substances injected into the marrow are absorbed almost immediately into the general circulation.

• Placing a central line (femoral subclavian, internal jugular) takes longer than an IO, but may be acceptable in older child, adolescent or adult
• Arterial line: Arteries cannot tolerate the massive fluids required for resuscitation.

Question 40

Antibiotic treatment for meningococcemia:

Answer 40

The most appropriate treatment for meningococcemia is penicillin G. Calculating doses for teenagers and large children is tricky. Double checking calculations with the formulary is an important step to preventing mistakes when prescribing medications.

Question 41

Infection control when treating a patient with meningococemia:

Answer 41

Household, childcare and nursery school contacts - and any healthcare workers having close contact with the patient before he/she received antibiotics should receive prophylaxis (ciprofloxacin for adults and rifampin or ceftriaxone for children)

Question 42

Immunization:

Answer 42

• For the general population, the tetravalent meningococcal conjugate vaccine (MCV4) is given intramuscularly to children ages 11-18, usually at the routine preadolescent visit.
• A booster dose should be given at age 16, before the peak in increased risk. (Adolescents who receive their first dose of MCV4 at or after age 16 years do not need a booster dose.)
• College freshman living in dorms are considered high risk and should receive a dose of the MCV4 vaccine within 5 years before starting college.
• The MCV4 vaccine is not recommended for children less than 2 years of age
• There are guidelines for certain other situations in high-risk children and adults in which administration of MCV4 is recommended