Sepsis and/or meningitis Flashcards
list signs of Clinical dehydration vs. Clinical shock in a child
Clinical dehydration Appears to be unwell or deteriorating Altered responsiveness Decreased urine output Skin colour unchanged Warm extremities
Clinical shock
Decreased level of consciousness
Pale or mottled skin
Cold extremities
Management of dehydration in a child
Oral rehydration
• Preferred option
• 50ml/kg low-osmolarity ORS solution over 4 hours + maintenance – little and often
• Continue breastfeeding
• Continue usual fluids – avoid high
sugar content fluids
• Consider NGT fluids if fails to tolerate
I.V. • Consider fluid bolus • Isotonic solution e.g. 0.9% sodium chloride with 5 % glucose – deficit & maintenance • Monitor response • Monitor electrolytes • Bewareofhypernatremic dehydration • Slowrehydration • To reduce sodium by 0.5 mmol/hr
Clinical features of Septic shock
• History–fever,rash,irritability, poor feeding
• Clinicalfeatures
• A + B – tachypnoea, shallow
breathing, recessions
• C–tachycardia,increasedCRT,low BP (late sign), cool peripheries (beware of warm shock)
• D–alteredconsciousness • E–rash
Management of septic shock
Management • A + B – Oxygen, positive pressure, intubation • C–fluidbolus–20ml/kg(mayneed more), inotropes • Treatment– • Antibiotics, • Manage temperature, • Correct metabolic & clotting abnormalities
Clinical features of Anaphylaxis in a child
- History–allergy,suddenonset wheezing
- Clinicalfeatures
- A–hoarseness,stridor
- B–tachypnoea,wheeze,cyanosis, decreased spO2
- C–tachycardia,pale,clammy, hypotension
- Skin–Urticarialrash
Management of anaphylaxis in a child
Management • A–supportit • B–oxygen • Intramuscular Adrenaline 1:1000 • Nebulisers • C–fluids • Other • Iv hydrocortisone • Iv chlorphenamine
Clinical features Status epilepticus in children
• History–epilepsy,familyhistory, illness, last meal • Clinicalfeatures • A+B–tachypnoea,erraticbreathing, cyanosis • C–tachycardia,variableBP • E–rash,neurocutaneousmarkers
Management of Status epilepticus in children
- A + B – oxygen, intubation
- Don’teverforgetglucose
- PR Diazepam / Buccal Midazolam
- C – fluids
- Iv Lorazepam
- PRParaldehyde
- Iv Phenytoin
- Other
- Considersepsis
- Correct metabolic abnormalities
Key differences when prescribing antibiotics in children vs adults
- Handling of drugs / dosing cannot always be extrapolated e.g Vancomycin, Ertapenem
- Tetracyclines contraindicated in children under 12 years ( BNF – others use 8 years ) (deposition in growing bone and teeth, by binding to calcium, causes staining and occasionally dental hypoplasia)
- Quinolones - adverse effects on cartilage development in juvenile animals through the inflammation and destruction of weight-bearing joints
- Macrolide antibiotics in the first two weeks of life appears to convey a risk of IHPS
Neonatal infection types
- Early / Late GBS
- HSV
- Listeria
- Chlamydia/gonococcal
- CMV
- TB
Microbes responsible for Neonatal meningitis
- Group B Streptococcus — 50 percent of cases • E. coli — 25 percent
- Other gram-negative rods — 8 percent
- Listeria monocytogenes — 6 percent
- Streptococcus pneumoniae — 5 percent • Group A Streptococcus — 4 percent
- Haemophilus influenzae — 3 percent
Why can any bacteraemia in neonates led to meningitis?
permeable BBB
Microbes responsible for infants and child meningitis
Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b
Microbes responsible for adolescent meningitis
Neisseria meningitidis, Streptococcus pneumoniae
CSF changes in meningitis
- Cell count > 20 cells/uL abnormal in neonates ( > 5 in others )
- CSF protein > 1.0 g/L abnormal in neonates ( 0.4 in others )
- Lymphocytic picture in Listeria
- Neutrophilic response in early phase of enterovirus meningitis
Importance of E.Coli 0157 diarrhoea in HUS
Haemolytic Uraemic syndrome in children – 83 % associated c E coli 0157
Treating infection with antibiotics more likely to cause HUS
Diarrhoea (often bloody)
Haematological – microangiopathic haemolytic anaemia , thrombocytopenia, acute renal failure
Management of Babies that are born to Hepatitis B positive mothers
- Babies that are born to Hepatitis B positive mothers, should be vaccinated within 24 hours of birth and referred for follow-on vaccinations at 1, 2 and 12 months of age with a blood test for infectivity status
- Specific indications for Hepatitis B immunoglobulins depending on HB eAg/Ab status and birthweight ( Green Book )
- No need for CS , allowed to breast feed
Management of Maternal Hepatitis C infection
- Risk of acquisition 2-8% • Allowed to breast feed • No need for CS
- Baby needs follow up testing HCV PCR at 6 wks , 12m , HCV Ab at 12 m and 18 m
Management of Maternal Syphilis infection
- Send a venous blood sample for serum RPR and treponemal IgM (take blood from the neonate, not the umbilical cord) at birth and 3 monthly until negative
- Approximately half of all neonates with congenital syphilis are normal on initial examination
- Further testing and treatment indicated if mother inadequately treated or infant has clinical signs consistent with syphilis
Management of HIV PEP for infant very low risk
• - Two weeks’ zidovudine monotherapy is recommended if all the following criteria are met:
• Mother has been on cART for longer than 10 weeks
AND
• Two documented maternal HIV viral loads <50 HIV RNA copies/mL during pregnancy
at least 4 weeks apart
AND
• Maternal HIV viral load <50 HIV RNA copies/mL
at or after 36 weeks
Management of HIV PEP for infant low risk
- Extend to 4 weeks’ zidovudine monotherapy:
- If the criteria for very low risk not fulfilled but maternal HIV VL is <50 HIV RNA at or after 36wks
- If baby born prematurely (<34 weeks) but most recent maternal HIV VL is <50 copies/mL
Management of HIV PEP for infant at high risk
• Use combination PEP if maternal birth HIV VL known to be or likely to be >50 copies/mL on day of birth, if uncertainty about recent maternal adherence or if VL not known.
• Neonatal PEP should be commenced very soon after birth, certainly within 4 hours.
• In the context of known maternal resistance to zidovudine with VERY LOW or LOW risk,zidovudine monotherapy is still
recommended for infant PEP.
Advice on Breastfeeding in HIV
- UK recommendation is to avoid breastfeeding with support for formula milk
- Women who are virologically suppressed on cART with good adherence and who choose to breastfeed may be supported to do so, but should be informed about the low risk of transmission of HIV through breastfeeding in this situation.
- Breast fed infants need regular HIV tests
Infant testing for HIV
• During the first 48 hours and prior to hospital discharge
• If HIGH RISK, at 2 weeks of age
• at 6 weeks (at least 2 weeks post cessation of infant prophylaxis*)
• at 12 weeks (at least 8 weeks post cessation of infant prophylaxis *)
• On other occasions if additional risk
• HIV antibody testing for seroreversion should be checked at age 18–24 months
*In very low risk neonatal PEP is for 2 weeks
