The Child in Shock

Question 1

What is shock?

Answer 1

An acute, life threatening syndrome of

Ciculatory dysfunction

Resulting in

Inadequate delivery of

Oxygen and other nutrients

To meet metabolic demand.

Question 2

What is the final pathway of shock?

Answer 2

• Inadequate
  
  • substrate delivery
  • removal of metabolites
• Cellular oxygen deficiency
• Anaerobic metabolism
• Cellular acidosis
• Loss of norma cellular function
• Cell death
• Organ dysfunction
• Death

Question 3

What are the factors affecting tissue perfusion and oxygen supply?

Answer 3

1. Blood volume
2. CO = HR X SV (stroke volume)
   
   • directly proportional to
     
     • preload (venous return)
     • afterload (SVR)
     • cardiac contractility
3. Arterial oxygen content
   
   • haemoglobin content
   • oxygenation

Insult affecting any of these can lead to shock.

Question 4

What are the 5 different types of shock?

Give examples (common ones in bold).

Answer 4

CHODD

1. Cardiogenic (defects of heart pump)
   
   • heart failure (cardiomyopathy, myocarditis)
   • arrhythmia
   • valvular disease
   • myocardial contusion
2. Hypovolaemic (loss of fluid)
   
   • haemorrhage
   • gastroenteritis, stomal losses
   • intususseption
   • volvulus
   • burns
   • peritonitis e.g. ruptured appendix
3. Obstructive (flow restriction)
   
   • congenital cardiac disease (coarctation, aortic stenosis, hypoplastic left heart)
   • tension PTX / haemothorax
   • flail chest (segment of the rib cage breaks due to trauma and becomes detatched from the rest of the chest wall)
   • cardiac tamponade
   • PE
4. Distributive (vessel abnormalities)
   
   • sepsis
   • anaphylaxis
   • drugs (vasodilating)
   • spina cord injury
5. Dissociative (inadequate oxygen releasing capacity of the blood)
   
   • anaemia (profound)
   • Carbon monoxide poisoning
   • methaemoglobinaemia

Question 5

What are the 3 phases of shock?

Describe them.

Answer 5

Progressive state

1. Compensated
2. Uncompensated
3. Irreversible

1. Compensated
   
   • perfusion to vital organs is maintained (brain, heart, kidneys)
   • sympathetic nervous system reflexes to maintain CO
     
     • increase SVR and divert blood away from non essential tissues
     • constrict venous reservoir (increased venous return)
     • increase HR
   • Systolic BP normal, Diastolic BP may be elevated due to incereased SVR
   • Fluid retention
     
     • kidneys conserve water and salt (due to angiotensin and vasopressin)
     • reduced urine output (due to reduced kidney perfusion)
     • intestinal fluid reabsorbed from the gut
   • Signs:
     
     • mild agitation or confusion
     • pallor
     • prolonged CRT
     • cool peripheries
     • Tachycardia
     • reduced urine output
   • Appropriate therapeutic intervention can completely reverse shock at this stage
2. Uncompensated
   
   • compensatory mechanisms above fail to support circulation
   • tissue is poorly perfused
   • switch to anaerobic metabolism (inefficient)
   • lactate production
   • failure to remove intracellular CO2
   • intracellular carbonic acid formed
   • ACIDOSIS
   • => reduced myocardial contractility
   • => impaired response to catecholamines
   • failure of the energy dependent Na-K pump - maintains the normal homeostatic env in cells for optimal function (due to inefficiency of anaerobic respiration)
   • => lysosomal, mitochondrial and cell membrane dysfunction
   • sluggish blood flow and chemical changes in small vessels
   • => platelet adhesion
   • => chain reactions in kinin and coagulation systems
   • => DIC
   • still reversible at this stage
   • Signs:
     
     • normal or falling BP
     • tachycardia
     • prolonged CRT
     • cold peripheries
     • acidotic breathing
     • depressed consciousness
     • reduced or absent UO
     • lactic acidosis on blood gas
3. Irreversible
   
   • cellular damage cannot be reversed
   • multiple organ failure
   • death

Question 6

Describe the primary assessment and resuscitation of shock.

Answer 6

• A
  
  • Airway opening manoeuvres
  • adjuncts
  • induction of anaesthesia –> I&V
• B
  
  • Signs
    
    • tachypnoea (acidotic breathing)
  • high flow O2 face mask + reservoir
  • high flow nasal cannulae
  • bag- valve- mask if hypoventilating
• C
  
  • HR, rhythm, BP, CRT, UO (urinary catheter)
  • 12 lead ECG if abnormal rhythm OR if HR
    
    • >200 infant
    • >150 child
  • Tachyarrhythmia
    
    • SHOCKS
      
      • up to 3 x synchronous shocks
        
        • 1.0 –> 2.0 –> 2.0 J/ kg
        • anaesthetise if conscious
      • asynchronous if broad complex and synchronous not possible
    • Adenosine
      
      • if narrow complex (SVT)
  • IV or IO access
  • 2 x large bore IV (femoral vein if IO difficult)
  • Ix
    
    • bloods - baseline + clotting + CRP / pro-calcitonin + (Ca) + Mg
    • cross match
    • meningococcal/ streptococcal PCR
    • BCx
    • blood gas (lactate, glucose, Hb, calcium)
  • Fluids
    
    • 20 ml/ kg or 5- 10 ml/kg (cardiac patients or raised ICP)
    • over 5-10 mins
    • Type of fluid
      
      • crystalloid (insufficient evidence for albumin but may trial if needing repeated boluses)
      • blood transfusion if haemolytic anaemia e.g. sickle cell crisis, malaria (only if not hypotensive)
    • Aims
      
      • reverse hypotension
      • UO > 1/ ml/ kg/ hour
      • normal CRT/ peripheral pulses
      • normal GCS
    • cardiogenic shock - call cardiologist
    • raised ICP
      
      • hypotension is detrimental for cerebral perfusion
      • too much fluid –> worsening cerebral oedema
  • Inotropes by IV/IO/ central line - if:
    
    • hypotension refractory to fluid resuscitation
    • signs of overload e.g. crackles, hepatomegaly
  • I+V
    
    • consider if > 40 ml/kg fluid boluses given
    • why?
      
      • decreases energy requirement of heart/ resp muscle
      • adequate oxygenation
      • reduced risk of pulm. oedema
      • allows placement of arterial line and central venous catheter
  • Trauma
    
    • control haemorrhage
      
      • external - direct pressure
      • internal
        
        • cautious fluids 5-10 ml/kg whilst awaiting surgery
        • no response to first 10 ml/kg then massive haemorrhage protocol
        • surgical assessment
        • balance risk and benefit of hypotensive resuscitation - in HI normalise BP to maintain cerebral perfusion
  • Anaphylaxis: Adrenaline IM
    
    • 10 microgram/ kg OR
    • 150 micrograms (<6)
    • 300 micrograms (6-12)
    • 500 micrograms (>12)
• D
  
  • AVPU/ GCS
  • PEARL
  • posture
  • signs
    
    • Agitation –>
    • Obtundation –>
    • Coma.
    • • Hypotonic posture
  • raised ICP
    
    • bradycardia
    • hypertension
    • posturing
    • seizures
    • decreasing conscious level
    • focal neurological signs e.g. unequal pupils
• E
  
  • Temp
    
    • fever
    • toe-core temp difference
  • Rash
    
    • haemorrhagic purpura
      
      • meningococcal sepsis
      • pneumococcal sepsis
    • generalised erythema + conjunctivitis +mucositis
      
      • TSS (toxic shock syndrome)
  • Consider IVAB if fever/ rash - ceftriaxone/ cefotaxime
• Glucose
  
  • Don’t ever forget glucose!
  • hypoglycaemia looks similar to compensated shock
  • sick children may not be eating well
  • children have limited glycogen reserves

Question 7

Name the cause of shock in children with the following features:

1. vomiting and diarrhoea
2. fever and rash
3. urticaria, angioneurotic oedema, allergen expsosure
4. 4-6 weeks old, grey colour or cyanosis unresponsive to O2 therapy + signs of heart failure
5. heart failure signs in an older child
6. sickle cell disease + low Hb
7. recent diarrhoeal illness + low Hb
8. sickle cell + abdo pain + enlarged spleen
9. major trauma
10. severe tachycardia + arrhythmia
11. polyuria/ polydipsia, acidotic breathing, high glucose
12. drug ingestion

Answer 7

Causes of shock:

1. Fluid loss
   
   • external e.g. gastroenteritis
   • internal (into the abdomen) e.g. volvulus, intussuscption, ruptured appendix
2. Sepsis
3. Anaphylaxis
4. Duct dependent congenital heart disease
5. Cardiompyopathy, myocarditis
6. Haemolysis
7. ”
8. Splenic sequestration
9. haemorrhage +/-
   
   • PTX / haemothorax
   • cardiac tamponade
   • spinal cord injury (transection)
10. cardiac cause
11. DKA
12. poisoning

Question 8

Are infants more likely than children to present with shock?

Why?

Answer 8

Yes.

• low physiological reserve
• increased susceptibility to conditions like
  
  • GE (external fluid loss)
    
    • may present primarily with shock
    • little history of diarrhoea or vomiting
    • massive loss of fluid from the bowel wall into the gut lumen, depleting intravascular volume
    • viruses most common
  • surgical abdomen e.g. volvulus (concealed/ internal fluid loss)

Question 9

Describe the emergency management of hypovolaemic shock due to non haemorrhagic fluid loss.

Answer 9

• ABCDEFG
• 20 ml/kg bolus IV crystalloid
• + catheterise
• REASSESS
• SIGNS OF SHOCK?
• 2nd bolus
  
  • 1-2 boluses usually sufficieny in GE
  • start immediate NG/ oral rehydration solution
  • restart feeding in 4-6 hrs
• Repeat gas + U+E
  
  • acidosis is corrected by Tx of shock
  • don’t need to replace bicarb unless lost in stool
• Correct hyponatraemia
  
  • Convulsions?
    
    • correct rapidly to Na 125 / or <125 if convulsion terminates
    • 4 ml/ kg of 3% NaCl – over 15 mins
  • No convulsions
    
    • slowly correct
    • max 8-12 mmol/ L / day
• Start IVAB - to cover for:
  
  • sepsis e.g. secndary to surgical abdo
  • TSS
• AXR/ USS - to look for:
  
  • distended bowel
  • intra abdominal air/ fluid
• +/- referral to surgeons e.g. if
  
  • ​bile stained vomiting
  • guarding
• STILL SHOCKED? Consider:
  
  • 3rd bolus
  • inotropes e.g. dopamine + invasive BP monitoring (CVP)
  • I+V (if needing more than 2 boluses i.e. 40 ml/kg)

Question 10

Define sepsis.

Answer 10

SEPTIC SHOCK

WITH

CARDIOVASCULAR END-ORGAN DYSFUNCTION

Question 11

What type of shock does sepsis cause?

Answer 11

MIXED - CHOD:

1. Cardiogenic (defects of heart pump) - impaired cardiac function due to:
   
   • hypovolaemia
   • myocardial suppressive factors release by
     
     • infective organisms
     • host inflammatory response
2. Hypovolaemic
   
   • loss of fluid
     
     • fever
     • D&V
     • anorexia
   • capillary leakage (increased vascular permeability)
3. [[Obstructive (flow restriction)]]
4. Distributive (vessel abnormalities)
   
   • altered vascular tone
   • some vascular beds vasoconstricted, other vasodilated
5. Dissociative (inadequate oxygen releasing capacity of the blood)
   
   • mitochondrial dysfunction impairs cellular oxygen utilisation

Question 12

Which age group has the highest incidence of sepsis?

Answer 12

Infants.

Question 13

What is the commonest cause of community acquired septicaemia in infants and children?

Name other common causative agents.

Answer 13

Neisseria meningitidis (meningococcus).

• GBS (infants)
• GAS
• Gram -ve sepsis (UTI/ gut problems)

Question 14

What sources of infection are important to consider in children with co-morbidities?

Answer 14

1. neurological
2. respiratory (impaired secretion clearance)
3. long term indwelling devices e.g. catheters, PICC lines

Question 15

Describe the rash in meningococcal septicaemia.

Answer 15

• purpuric rash
• blanching erythematous rash (15%)
  
  • replaces or
  • precedes
• no rash (7%)

Question 16

Describe the clinical picture of TSS (top to bottom).

Answer 16

TOP TO BOTTOM

• high fever
• diffuse erythema –> scarlantiform rash
• SC oedema
• headache
• confusion
• conjunctival and mucosal hyperaemia (strawberry tongue)
• vomiting
• watery diarrhoea

+/-

• trivial injury
  
  • infected wound/ cut/ scratch
  • minor burn/ scald
  • surgical wound infection
• deep-seated infection (co-existent)
  
  • pneumonia
  • bone/ joint

Question 17

Describe the emergency Mx of TSS.

Answer 17

1. Fluids
2. IVAB - CLINDAMYCIN (anti-staphyloccocal)
3. IVIG
4. Drainage of localised pus

Question 18

Describe the emergency management of septic shock.

Answer 18

1. Fluids
   
   • crystalloid or colloid
   • needing > 40 ml/kg
     
     • involve CATS/ PICU
     • 3rd bolus
     • inotropes (reduced risk of HF caused by fluid overload - more likely if cardiac pt/ severe anaemia/ malnutrition already present)
     • NB give IV/IO if no central line but dilute NA/ Adr. by 10x
       
       • HYPODYNAMIC shock + HIGH SVR (COLD peripheries)
         
         • dopamine 10 -20 mcg/kg/min
         • adrenaline 0.05 - 2 mcg /kg/min
           
           • if rapidly deteriorating
           • greater B2 effects in peripheral vasc. => vasodilation
       • HYPERDYNAMIC SHOCK + lOW SVR (WARM peripheries)
         
         • noradrenaline 0.05 - 2 mcg /kg/min
     • ? ADRENAL INSUFFICIENCY
       
       • HYDROCORTISONE 50 mg/ kg/ day - cont. infusion
       • take blood for cortisol
     • I+V (reduced heart/ resp muscle energy requirement, adequate oxygenation, reduced risk of fluid overload, placement or art + central lines - femoral or IJ)
     • Monitoring:
       
       • sats
       • capnography
       • blood gases
       • CVP
2. IVAB
   
   • BCx first if possible
   • ceftriaxone /
   • cefotaxime (CALI JAP)
     
     • Premature
     • Jaundiced (infant)
     • Low Albumin
     • CALcium Infusion
   • clindamycin (TSS)
   • < 3 months + amoxicillin (listeria)
   • TAZOCIN
     
     • hospital acquired
     • neutropaenia
   • Previous RESISTANT organism?
     
     • MRSA -> Vancomycin
     • ESBL -> Meropenem
   • IV access > 48 hrs -> + vancomycin

Question 19

Describe the emergency Rx of shock + meningitis with ICP.

Answer 19

• A
• B
  
  • support ventilation
  • I+V if signs of raised ICP persist
  • aim PCO2 4.5 - 5.5
• C
  
  • Rx of shock takes priority > ICP
  • maintanin BP + cerebral perfusion
  • nurse 20 degrees head up (improve cerebral venous drainage)
  • urinary catheter
• D
  
  • avoid LP (coning of brain stem through foramen magnum)

Question 20

What is anaphylaxis?

Answer 20

Potentially LIFE-THREATENING

IMMUNOLOGICALLY mediated rxn to

INGESTED/ INHALED/ TOPICAL substances

which may present as

SHOCK/ RESP DISTRESS.

Question 21

Name some common triggers of anaphylaxis.

Answer 21

• Food: nuts, fish, eggs
• Drugs: penicillin, Anaesthetic agents
• Radiographic contrast

Question 22

What blood test can be used to confirm the diagnosis of anaphylaxis?

Answer 22

Mast cell tryptase.

Question 23

What are life threatening features in anaphylaxis?

Answer 23

1. DIB - stridor / wheeze
2. Shock - vasodilation + increased capillary permeability = intravascular fluid depletion

Question 24

What are the signs of anaphylaxis?

Answer 24

1. CV
   
   • tachycardia
   • hypotension
   • poor pulse volume
   • pallor
   • cardiac arrest
2. Resp
   
   • wheeze
   • stridor
   • cyanosis
   • resp arrest
3. Skin
   
   • urticaria
   • angio-oedema
   • conjunctivitis
   • flushing
   • sweating
4. GI
   
   • abdo pain
   • nausea
   • D&V
5. Neuro
   
   • agitation
   • restlessness
   • collapse

Question 25

What signs in the history suggest severe allergic rxn?

Answer 25

1. Previous severe allergic rxn/ increasingly severe rxns
2. Asthma
3. B blockers

Question 26

Describe the emergency Mx of anaphylaxis.

Answer 26

1. CALL FOR HELP
2. Remove allergen
3. 100% O2 FM
4. IM adrenaline 1:1000 (older kids) or 1:10,000 (younger) - every 5 MINS
   
   • 10 mcg/ kg or
   • 150 mcg (<6)
   • 300 mcg (6-12)
   • 500 mcg (>12)
5. A
   
   • complete obstruction –> I+V/ surgical airway
   • partial obstruction/ stridor
     
     • IM adrenaline x 2 if no response
     • nebulised adrenaline 400 mcg/ kg or 0.4 ml/kg of 1:1000 (max 5 ml)
     • rpt every 10 mins
     • HYDROCORTISONE IV
6. B
   
   • apnoea
     
     • BVM or ETT ventilation
     • IM adrenaline repeat
     • hydrocortisone
   • wheeze
     
     • rpt IM Adrenaline
     • salbutamol neb
     • hydrocort IV + antihistamine
     • salbutamol/ aminophylline IV
7. C
   
   • no pulse –> BLS / ALS
   • shock
     
     • repeat IM adrenaline
     • fluid bolus
     • IV adrenaline 1 mcg/ kg over 1 min
     • can dilute 1x adrenaline in 10 ml saline => 1 mcg/ kg/ ml solution
     • Additional inotropes not necessary
8. REASSESS

Question 27

What does the ductus arteriosus connect?

Answer 27

The systemic and pulmonary circulations,

in fetal life.

Question 28

Give examples of duct dependent pulmonary & systemic circulation & mixed.

Answer 28

Duct - dependent PULMONARY circulation:

• pulmonary atresia (sheet of tissue or muscle instead of a proper valve, blood supply to R heart from foramen ovale/ VSD & to lungs through PDA, may have small RV)
• tricuspid atresia (sheet of tissue or muscle instead of a proper valve, no blood goes to RV, underdeveloped R heart, ASD/ patent foramen ovale, +/- VSD)
• TOF (tetrallogy of fallot) = pulmonary stenosis, VSD, overriding aorta, RV hypertophy => R to L shunt)
• critical pulmonary stenosis

Duct - dependent SYSTEMIC circulation:

• coarctation of the aorta (narrowing, usually at the point of insertion of the ductus arteriosus/ ligamentum arteriosum, reduced blood supply to the lower body, may have absent femoral pulses)
• critical aortic stenosis
• hypoplastic left heart syndrome
• interrupted aortic arch (aorta not completely developed, gap b/w ascending and descending thoracic aorta)

Duct - dependent for BOTH circulations:

• Transposition of the great arteries (abnormal spatial arrangement of pulmonary artery and aorta)

Question 29

How do infants with duct-dependent pulmonary and systemic circulations present?

Answer 29

Duct dependent PULMONARY:

• first few days
• increasing cyanosis unresponsive to oxygen therapy
• signs of severe hypoxaemia
• LITTLE resp distress
• signs of cardiogenic shock (tachypnoea, tachycardia, enlarged liver)
• often NO murmur

Duct dependent SYSTEMIC:

• first few days
• inability to feed
• breathlessness
• grey colour
• collapse/ poor peripheral circulation
• difficult to feel pulses + different in upper & lower limb pulses (obstruction to L heart outflow)
• cardiogenic shock
• very sick - metabolic acidosis/ poor UO/ reduced consciousness

Question 30

What are the signs of heart failure (top to bottom)?

Answer 30

From top to bottom:

• Cyanosis - not corrected by O2 therapy, or Pallor/ Grey
• Sweating, restlessness, fatigue/ effort intolerance in older children
• Feeding difficulty, growth failure, anorexia
• JVP - raised
• Chest pain
• Tachycardia - out of proportion to WOB - & Tachypnoea
• Cough
• Inspiratory crackles
• Heart enlarged, displaced apex beat (CXR large heart and pulmonary congestion)
• Gallop rhythm/ murmur
• Liver enlarged
• Abdominal pain
• Femoral pulses absent
• Cool peripheries (Cardiogenic shock)

Question 31

Describe the emergency Mx of congenital heart disease.

Answer 31

• B
  
  • O2 of little benefit and may cause the duct to close sooner
  • Low threshold for I+V (in cardiogenic shock)
  • NB anaesthetic induction agents can worsen things - call PICU + cardiologist
• C - keep the duct open!!!
  
  • DINOPROSTONE (prostaglandin E2) or
  • ALPROSTADIL
    
    • well/ no acidosis –> 10-15 nanograms/kg/min
    • unwell/ acidosis –> 20 nanograms/kg/min –> 1 hour no response –> 50 nanograms/kg/min
    • SE’s
      
      • apnoea –> I+V
      • hypotension (due to vasodilation) –> fluid bolus
• Aims
  
  • Duct-dependent PULMONARY (R side obstruction)
    
    • sats 75-85%
    • normal lactate
  • Duct-dependent SYSTEMIC (L side obstruction) - PP
    
    • palpable pulses
    • normal pH + lactate
• Referral - PICU + cardiology
  
  • TGA/ HLHS or HRHS
  • • sats <70%
  • • lactate worsening
  • => may need ATRIAL SEPTOTOMY
• Ix
  
  • CXR
  • ECG 12 LEAD
  • Bloods incl. U+E/ calcium/ glucose/ lactate
  • ABG
  • BCx
  • pre + post ductal sats
    
    • right hand = pre-ductal, foot = post ductal
    • difference of > or = 10% = PPHN (persistent pulmonary HTN) & R-> L shunt

Question 32

How does the fetal circulation change in the neonatal period?

Answer 32

• Fetal
  
  • high Pulmonary vascular resistance
  • blood bypasses the lungs via PDA, foramen ovale i.e. R –> L shunt
• Neonatal
  
  • lung inflation and oxygenation
  • pulm. vascular resistance falls
  • Higher pressure in L > R heart
  • foramen ovale closes
  • PDA closes and becomes the ligaementum arteriosum in time

Question 33

What can cause PPHN? (Peristent pulmonary hypertension of the newborn)

Answer 33

1. Congenital heart disease
2. abnormal pulmonary VASCULATURE development e.g.
   
   • chronic fetal hypoxia causes increased smooth muscle in pulm vasculature
   • maternal diabetes
3. abnormal PULMONARY development (pulmonary hypoplasia) WITH abnormal pulm. vasc. e.g.
   
   • congenital diaphragmatic hernia
   • potter’s syndrome
   • prolonged oligohydramnios
4. pulmonary VASPCONSTRICTORS elevated in the postnatal period e.g.
   
   • sepsis
   • pneumonia
   • perinatal asphyxia
   • aspiration syndromes

Question 34

Describe the emergency management of shock secondary to cardiomyopathy.

How do they present?

Answer 34

May present with Arrhythmias, Heart failure OR Shock.

No H/O Congenital heart Dz.

• B
  
  • 100% O2 no rebreather mask
• C
  
  • Heart failure –> American Heart Association guidance
    
    • ACEI
    • Diuretics (if not shocked e.g. IV frusemide 0.5 - 1 mg/ kg
  • Shock
    
    • Fluids
      
      • cautious
      • 5-10 ml/ kg
    • INOTROPES - adrenaline (CVC/ IV/ IO) or dobutamine
    • avoid aggressive fluid resus
    • ECMO (extra corporeal membrane oxygenation) + ventricular assist devices
• Ix
  
  • CXR
  • ECG
  • Bloods incl. U+E/ Ca/ lactate/ glucose
  • BCx
  • ABG
  • ECHO
• stabilise and transfer to paediatric cardiac centre

Question 35

What is defined as severe anaemia?

Answer 35

Hb < 50

Question 36

Describe the signs of severe anaemia caused by acute haemolysis (top to bottom).

Answer 36

• Skin: palms and soles near white
• Neuro: lethargic
• CVS: signs of heart failure
• Renal: urine dark brown

Question 37

Name the most common situation in which children develop sudden severe haemolysis?

Name some other situations.

Answer 37

Most common:

1. HUS
2. sickle cell disease + sepsis

Other:

1. Malaria (severe anaemia with or without haemolysis)

Question 38

What is HUS?

Describe the symptoms and causative agents.

Answer 38

Haemolytic uraemic syndrome

1. microangiopathic haemolytic anaemia => low RBC + jaundice
2. thrombotic microangiopathy => low platelets
3. acute kidney failure => blood in urine + high BP

Sx:

1. bloody diarrhoea (dysentery)
2. vomiting
3. abdo pain
4. fever
5. weakness
6. low urine output / dehydration
7. jaundice

Pathogens:

1. E. Coli (most common)
2. Shigella
3. Salmonella
4. Strep pneumo

Question 39

Describe the emergency Mx of profound anaemia.

Answer 39

• TRANSFUSION if Hb < 50
• heart failure?
  
  • exchange transfusion
  • diuretics
• sepsis?
  
  • fluids +- inotropes
  • IVAB

Question 40

Decsribe the different types of sickle cell crises.

Answer 40

V .C A S H

1. Vaso-occlusive
   
   • Most common
   • red cells clog small vessels
   • tissue ischaemia
2. Acute Chest syndrome
3. Aplastic crisis
4. Sequestration crisis
   
   • pooling of blood in the spleen and liver
   • severe anaemia and hypotension
5. Hyper-haemolytic crisis

Question 41

What factors are thought to precipitate sickle cell crises?

Answer 41

I D . C A S H

• infections
• dehydration
• cold
• acidosis
• stress
• hypoxia

Question 42

Describe the components of the emergency Mx of sickle cell crises.

Answer 42

• B
  
  • O2
• C
  
  • rehydration
  • antibiotics
  • analgesia incl. parenteral morphine (vaso occlusive crises & acute chest crises)

Question 43

Is dextrose a suitable fluid for resuscitation? Why?

Answer 43

No.

Lowers sodium, predisposing to hyponatraemic seizures.

Question 44

Which type of fluid should be used for resuscitation.

Answer 44

Topic of ongoing debate.

1. Crystalloids
   
   • when small volumes needed, up to 40 ml/kg
   • usually more readily available
   • Downsides:
     
     • diffuse more readily into interstitial space & allow water to diffuse into interstitial space if there is capillary leak => more likely to cause peripheral oedema
     • need larger volume than colloid to expand the vascular space
     • may cause acidosis (due to non-physiological chloride levels + no buffer)
2. Colloids
   
   • less readily available
   • Upsides are the opposite to above
   • use if large volumes are needed
3. Blood
   
   • if needing > 40 ml/kg then consider transfusion (circulating volume kids 80 ml/ kg => avoid haemodilution)
   • Guides:
     
     • CVP & UO for degree of fluid resuscitation
     • haematocrit for need for transfusion
   • take a full cross match
   • emergencies
     
     • ABO rhesus matched (15 mins)
     • O -ve

Question 45

How does volume of fluid and rapidity of fluid resuscitation affect outcome in

(A) sepsis

(B) penetrating trauma requiring definitive surgical Mx

Answer 45

• Sepsis
  
  • aggressive fluid resuscitation
  • > 40 ml/ kg in the first hour
  • better outcome
• Penetrating trauma
  
  • delay maximal fluid resuscitation until surgery

Question 46

What is the antibiotic of choice in the following cases of sepsis:

1. Central line infection
2. Hospital acquired or neutropaenic
3. Premature or jaundiced infants
4. TSS
5. Less than 3 months old

Answer 46

ANTIBIOTIC OF CHOICE

SEPSIS

1. Central line infection - Vancomycin
2. Hospital acquired or neutropaenic - Tazobactam
3. Premature or jaundiced infants - Cefotaxime (not ceftriaxone)
4. TSS - Clindamycin or other anti-staphylococcal
5. Less than 3 months old - Amoxicillin