Session 6 - Group Work Flashcards
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
a) Are these observations normal?
No,
BP low HR high O2 sats low RR high Temperature high
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
b) If not, what are the normal parameters?
BP 80-100 HR 95-150 O2 sats >96% RR 25-35 T 36.5-37.5
(Paediatric 2 y/o approx.)
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
c) How do the normal ranges alter with age?
HR and RR go down with age, BP systolic goes up with age.
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
d) What is the definition of sepsis?
Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
Sepsis is the body’s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death.
Paediatric:
Sepsis is SIRS + infection
Severe sepsis is SIRS + infection + organ dysfunction
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
e) How does this differ from bacteraemia?
The presence of bacteria in the blood.
Bacteraemia does not necessarily cause major damage.
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
f) List 2 common organisms that may be the cause of her presentation
Neisseria meningitides
Streptococcus pneumonia
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
g) What is the initial management of sepsis? (Think about the sepsis 6, refer back to your lecture and the Infection module)
Sepsis 6 bundle BUFALO - Take bloods - Urine output - Give fluids - Give IV antibiotics - Lactate - Oxygen (this will be done on a paediatric ward)
- Begin high flow O2
- Establish IO/IV access
- Begin IVO infusion
- Consider fluids
(Consider this support for ICU Consultant - so unwell you sent them to ITU for inotropic support, but you would not do this on the ward)
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
Mum then tells you that Poppy has had a reduced oral intake today, and that she has barely passed any urine in the past 12 hours. Clinically she appears dehydrated.
h) What are the symptoms and signs of hypovolaemic shock?
Rapid heartbeat. Quick, shallow breathing. Feeling weak. Being tired. Confusion or wooziness. Little or no pee. Low blood pressure. Cool, clammy skin.
Palor etc.
Change in demeanour
In neonates:
- check for the sunken anterior fontanelle (indirect measurement of the ICP)
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
Mum then tells you that Poppy has had a reduced oral intake today, and that she has barely passed any urine in the past 12 hours. Clinically she appears dehydrated.
i) Describe the response of the kidney in hypovolaemia (Refer to the Urinary module)
In states of hypovolemia, baroreceptors in the carotid sinus (high pressure) and left atria (low pressure) respond to decreases in pressure caused by decreases in effective circulating volume (hypovolemia) by stimulating ADH release, which causes water without sodium retention in the kidneys. This is accomplished via stimulation (opening) of water channels (aquaporins) in the collecting tubules, which then permit water to move down a concentration gradient into the hypertonic renal medulla (hence you need a hypertonic medulla in order for ADH to conserve water and concentrate urine). Catecholamine release is also stimulated and causes sodium and water absorption in the proximal tubules of the kidney and vasoconstriction as well as stimulation of renin release. Decreased arterial pressure in the afferent arteriole of the glomerulus stimulates the renin-angiotensin-aldosterone system, which causes sodium and water absorption in the distal nephron (under the influence of aldosterone) and proximal tubules (under the influence of angiotensinII) and thirst (water intake without sodium, in response to angiotensinII). Aldosterone simultaneously stimulates K excretion in exchange for sodium and also stimulates hydrogen (acid) excretion by stimulating the H-ATPase. AngiotensinII also stimulates acid excretion via stimulating renal ammoniagenesis in the proximal tubules (NH4Cl loss). These responses to hypovolemia are very effective at restoring blood volume or effective circulating volume, particularly the thirst reflex and aldosterone.
- Upregulation of RAS to increase ADH etc.
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
Mum then tells you that Poppy has had a reduced oral intake today, and that she has barely passed any urine in the past 12 hours. Clinically she appears dehydrated.
j) What is the management of hypovolaemic shock, what type of fluid might you give?
Give a fluid that is isotonic
20 mg/kg isotonic saline bolus in adults
20 mg/kg give (high %) dextrose and 0.45% saline, or just dextrose, in paediatrics
This is in a resusc. situation so you would need to calculate the level of dehydration
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
Mum then tells you that Poppy has had a reduced oral intake today, and that she has barely passed any urine in the past 12 hours. Clinically she appears dehydrated.
k) How does hypovolaemic shock differ from septic shock? (Refer to CVS/Infection modules)
Hypovolaemic shock is to do with reduced blood volume
Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.
- inflammatory cytokines cause the vasodilation in septic shock. Usually the bacterial endotoxin will activate the cytokines etc.
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
Mum then tells you that Poppy has had a reduced oral intake today, and that she has barely passed any urine in the past 12 hours. Clinically she appears dehydrated.
l) Why might this difference be important clinically?
With septic shock, you will need to treat the septic cause (infection) as well as the shock and give fluids, with hypovolaemic shock need to treat the shock so might need a blood transfusion for example.
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
Mum then tells you that Poppy has had a reduced oral intake today, and that she has barely passed any urine in the past 12 hours. Clinically she appears dehydrated.
m) Explain why children are more likely to become dehydrated than adults? Think about behaviourally and physiologically.
Behavioural:
- need to be fed (dependent)
- may not want to drink (fussy)
- exercise from playing
- can’t tell they’re thirsty/or communicate that - they forget they’re thirsty when playing
Physiologically:
- high surface area to volume ratio (diffusion)
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
Mum then tells you that Poppy has had a reduced oral intake today, and that she has barely passed any urine in the past 12 hours. Clinically she appears dehydrated.
You decide to perform an arterial blood gas; the results are as follows: pH 7.1 (7.35-7.45) pCO2 3.9 (4.5-6.0) pO2 8.7 (10-13.3) HCO3 18 (21-29)
n) Describe the results of the gas (refer to Respiratory/Urinary)
pH low
pCO2 low
pO2 low
HCO2 low
Uncompensated metabolic acidosis
1) You are the SHO covering the Paediatric Emergency Department on a Friday night. A mother enters the department with her 2-year-old child, Poppy, who is currently pale, unresponsive and floppy. The mother is visibly distressed and tells you that Poppy has had a “bad cold” for about a week but became suddenly more unwell this evening.
Poppy is immediately assessed by a paediatric nurse, who gives you the following observations: BP 72/50 HR 175 O2 sats 80% RR 45 T 39.5
You suspect a diagnosis of sepsis based on the brief history and the observations.
Mum then tells you that Poppy has had a reduced oral intake today, and that she has barely passed any urine in the past 12 hours. Clinically she appears dehydrated.
You decide to perform an arterial blood gas; the results are as follows: pH 7.1 (7.35-7.45) pCO2 3.9 (4.5-6.0) pO2 8.7 (10-13.3) HCO3 18 (21-29)
o) What may have caused the change in pH?
Reduced bicarbonate recovery from the kidneys
