Paediatric emergencies

Question 1

Name the most common micro-organisms causing sepsis

Answer 1

Bacteria:

• coagulase-negative Staphylococcus
• Staph. aureus
• non-pyogenic streptococci
• Strep. pneumoniae
• Neissseria meningitidis
• E. coli

Question 2

Suggest examples of sepsis red flags.

Answer 2

1. Appearance
   - appears ill to healthcare professional
   - looks mottled/ashen
   - cyanosis of skin, lips or tongue
   - non-blanching rash
2. Breathing
   - grunting/apnoea
   - SpO2 <90% in air or increased O2 requirement over baseline
   - RR >60/min for <1 yo, >50/min for 1-2 yo, >40/min for 3-4 yo
3. Circulation
   - HR <60/min
   - HR >160/min for <1 yo, >150/min for 1-2 yo, >140/min for 3-4 yo
4. Demeanor
   - no response to social cues
   - does not wake
   - if roused does not stay awake
   - weak high-pitched or continuous cry
5. Exposure
   - temp <36 C
   - temp >38 C in <3 mths old

Question 3

How would you manage a child presenting with sepsis?

Answer 3

1. Administer high O2 - titrate aiming for SpO2 >94%
2. Obtain IV/IO access and take bloods
   - blood culture
   - blood gas for glucose and lactate
   - FBC, CRP, coagulation and U/Es
3. LP unless contraindicated if <1 mth old or 1-3 mth old + looks unwell or has WBC <5 or >15, and consider urine, CSF or line cultures and meningococcal PCR
4. Give broad spectrum IV or IO antibiotics
5. Consider fluid resuscitation: 20 ml/kg (10 ml/kg if <28 days) 0.9% NaCl over 5-10 mins, repeat if necessary
6. Escalation - review by senior clinician St4+, discuss with consultant paed/PICU if lactate >4 mmol/l or no clinical improvement following second fluid bolus
7. consider inotropic support (adrenaline infusion IV/IO) if normal physiological parameters not restored after 40 ml/kg fluids

Question 4

Which broad spectrum antibiotics would you prescribe a child presenting with sepsis (according to age group)?

Answer 4

1. <28 days: IV gentamicin + amoxicillin (listeria cover) + cefotaxime
2. 1-3 mths: IV amoxicillin + ceftriaxone
3. > 3 mths: IV ceftriaxone

Question 5

Why is cefotaxime preferred in neonates compared to ceftriaxone?

Answer 5

Less likely to cause cholestasis/jaundice and can be given alongside Ca2+. But has to be given QDS.

Question 6

Describe the most common organisms causing meningitis in different age groups.

Answer 6

Viral infections most common cause:

• enteroviruses (Coxsackie or Echovirus)
• Herpes viruses (HSV or VZV)
• mumps or measles

Bacterial causes:

• neonates: group B strep., Listeria monocytogenes, E. coli
• <4 yrs: H. influenzae type B, N. meningitidis, Strep. pneumoniae
• > 4 yrs: N. meningitidis, Strep. pneumoniae

Question 7

Suggest possible risk factors for neonatal meningitis

Answer 7

• low birth weight
• premature delivery
• PROM
• traumatic delivery
• foetal hypoxia
• maternal peripartum infection

Question 8

Which investigations would you perform on a child presenting with suspected meningitis?

Answer 8

1. Bloods
   - blood culture
   - blood gas - for lactate, bicarb and glucose
   - FBC, CRP, U/Es, bone profile, clotting
   - meningococcal and pneumococcal PCR
2. urine MC+S, throat swab
3. LP - send for
   - microscopy
   - culture + sensitivities
   - gram stain
   - HSV, VZV + enterovirus PCR
   - chemistry: glucose + protein

Question 9

Describe your initial management of a child presenting with meningitis

Answer 9

1. A-E assessment and management as required, e.g. O2, IV fluids
2. Broad-spectrum antibiotics
   - neonate: IV gentamicin + amoxicillin + cefotaxime
   - 1-3 mths: IV amoxicillin + ceftriaxone
   - >3 mths: IV ceftriaxone
3. Steroids (IV dexamethasone) within 12 hrs since 1st Abx dose to decrease risk of cerebral oedema caused by bacterial cell lysis if: >3 mths + LP shows: frank purulent CSF, CSF protein >1 g/L or bacteria on gram stain
4. Notify Public Health England

Question 10

which CSF findings would increase likelihood of a bacterial meningitis? a viral meningitis?

Answer 10

Bacterial

• raised neutrophils (WCC>5 in >28 days or >20 in <28 days)
• raised protein (>1 g/L)
• low glucose (<50% serum Glu)

Viral

• raised lymphocytes
• normal glucose (>50% serum Glu)
• normal or high protein

Question 11

how would you treat a child with viral meningitis?

Answer 11

• supportive treatment only for most

- IV acyclovir if herpes meningitis

Question 12

Suggest possible acute and long-term complications of bacterial meningitis

Answer 12

Acute

• cerebral abscess
• subdural empyema
• RICP and death

Long-term

• cerebral palsy
• general learning disability (cerebral infarction)
• seizures/epilepsy (neuronal foci don’t develop properly)
• microcephaly
• visual impairment
• hearing loss