Peds 23 Flashcards
What are some compensatory mechanisms that children can have during shock?
- Increased Pulse (tachycardia)
- Increased heart contractility
- Increased venous tone
- Increased respiratory rate (tachypnea)
What are some clinical manifestations of shock?
Increased pulse, RR Cool, clammy extremities Delayed cap refill Decreased peripheral pulses Difficulty obtaining a pulse ox
What IV fluids would you order to initial management of shock?
NS 20 mL/kg over 5 to 20 minutes - boluses
Sarah is a previously healthy 15-year-old female who presents in compensated shock after the acute onset of fever and altered mental status. Exam is significant for petechial/purpuric rash and nuchal rigidity.
What’s the leading dx & treatment?
Meningococcal sepsis
Antibiotics (Ceftriaxone & Vancomycin)
What do you tell family members, for infection control purposes, after a patient is dx with meningococcal sepsis?
All household contacts and anyone having close contact during management of the patient should be treated with either ciprofloxacin, rifampin, or 1 dose of ceftriaxone.
A 6-year-old male presents to the ED with three days of diffuse muscle aches and occasional chills. Today, he has headache and abdominal pain. He reports that he does not feel hungry because he feels sick to his stomach. He reports no 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 several petechiae on his wrists and ankles. Upon questioning, his mother says that the spots began on his wrists and then spread to 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’s your leading dx? What is the best next step in management?
Rocky Mountain Spotted Fever
Obtain CBC, blood and CSF cultures, then give loading doses of doxycycline and ceftriaxone
The mother of a 5-year-old boy calls your office asking if she should take her son to the emergency department 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?
A. Have the patient hydrate well over the weekend and follow up with you in a few days
B. Have the patient make an appointment to come to your office today
C. Recommend ipecac to induce emesis and call 911
D. Tell the mother to take her son to an ED immediately or call 911 if they are unable to drive there immediately
D. Tell the mother to take her son to an ED immediately or call 911 if they are unable to drive there immediately
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, Pulse 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?
A. Obtain a head CT B. Order blood cultures C. Order CBC, CMP, PT, and INR D. Place IV and start NS bolus E. Perform a lumbar puncture.
D. Place IV and start NS bolus
A 12-day-old baby is brought to the ED by her mother due to fussiness and tactile fevers. The baby’s mother did not receive prenatal care and delivered her baby at home without medical assistance. On further questioning, you find out that the patient has had only two wet diapers per day and two loose green stools per day. On exam, the patient is irritable and her anterior fontanelle is bulging. Which of the following possible diagnoses is of most emergent concern at this time?
A. Bacterial sepsis/meningitis B. Down syndrome C. Fetal alcohol syndrome D. Metabolic disorder E. Meconium ileus
A. Bacterial sepsis/meningitis
A 16-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 or pull away from you 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 after stabilization?
A. Chest x-ray
B. Electroencephalogram (EEG)
C. Lumbar puncture
D. Toxicology screen
C. Lumbar puncture
A young child with fever and altered level of consciousness should lead to 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 young children 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).
What is the most sensitive measure of adequacy of circulation?
Pulse
What are 4 signs of meningitis (seen more in adults than children)?
- Neck stiffness (nuchal rigidity)
- fever
- altered mental status
- positive Kernig’s sign (inability to straighten leg when hip is flexed to 90 degrees
Once a patient suspected to have meningitis is stable after a couple of bolus fluids, you decide to draw some labs. How would a high BUN and creatinine result change your current management?
Adjust med doses for renal insufficiency
Continue fluids as needed until perfusion normalizes
