The Child in Shock Flashcards
1
Q
What is shock?
A
An acute, life threatening syndrome of
Ciculatory dysfunction
Resulting in
Inadequate delivery of
Oxygen and other nutrients
To meet metabolic demand.
2
Q
What is the final pathway of shock?
A
- Inadequate
- substrate delivery
- removal of metabolites
- Cellular oxygen deficiency
- Anaerobic metabolism
- Cellular acidosis
- Loss of norma cellular function
- Cell death
- Organ dysfunction
- Death
3
Q
What are the factors affecting tissue perfusion and oxygen supply?
A
- Blood volume
- CO = HR X SV (stroke volume)
- directly proportional to
- preload (venous return)
- afterload (SVR)
- cardiac contractility
- directly proportional to
- Arterial oxygen content
- haemoglobin content
- oxygenation
Insult affecting any of these can lead to shock.
4
Q
What are the 5 different types of shock?
Give examples (common ones in bold).
A
CHODD
- Cardiogenic (defects of heart pump)
- heart failure (cardiomyopathy, myocarditis)
- arrhythmia
- valvular disease
- myocardial contusion
- Hypovolaemic (loss of fluid)
- haemorrhage
- gastroenteritis, stomal losses
- intususseption
- volvulus
- burns
- peritonitis e.g. ruptured appendix
- 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
- Distributive (vessel abnormalities)
- sepsis
- anaphylaxis
- drugs (vasodilating)
- spina cord injury
- Dissociative (inadequate oxygen releasing capacity of the blood)
- anaemia (profound)
- Carbon monoxide poisoning
- methaemoglobinaemia
5
Q
What are the 3 phases of shock?
Describe them.
A
Progressive state
- Compensated
- Uncompensated
- Irreversible
- 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
- 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
- Irreversible
- cellular damage cannot be reversed
- multiple organ failure
- death
6
Q
Describe the primary assessment and resuscitation of shock.
A
- 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
- Signs
- 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
- up to 3 x synchronous shocks
- Adenosine
- if narrow complex (SVT)
- SHOCKS
- 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
- control haemorrhage
- 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)
- haemorrhagic purpura
- Consider IVAB if fever/ rash - ceftriaxone/ cefotaxime
- Temp
- Glucose
- Don’t ever forget glucose!
- hypoglycaemia looks similar to compensated shock
- sick children may not be eating well
- children have limited glycogen reserves
7
Q
Name the cause of shock in children with the following features:
- vomiting and diarrhoea
- fever and rash
- urticaria, angioneurotic oedema, allergen expsosure
- 4-6 weeks old, grey colour or cyanosis unresponsive to O2 therapy + signs of heart failure
- heart failure signs in an older child
- sickle cell disease + low Hb
- recent diarrhoeal illness + low Hb
- sickle cell + abdo pain + enlarged spleen
- major trauma
- severe tachycardia + arrhythmia
- polyuria/ polydipsia, acidotic breathing, high glucose
- drug ingestion
A
Causes of shock:
- Fluid loss
- external e.g. gastroenteritis
- internal (into the abdomen) e.g. volvulus, intussuscption, ruptured appendix
- Sepsis
- Anaphylaxis
- Duct dependent congenital heart disease
- Cardiompyopathy, myocarditis
- Haemolysis
- ”
- Splenic sequestration
- haemorrhage +/-
- PTX / haemothorax
- cardiac tamponade
- spinal cord injury (transection)
- cardiac cause
- DKA
- poisoning
8
Q
Are infants more likely than children to present with shock?
Why?
A
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)
- GE (external fluid loss)
9
Q
Describe the emergency management of hypovolaemic shock due to non haemorrhagic fluid loss.
A
- 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
- Convulsions?
- 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)
10
Q
Define sepsis.
A
SEPTIC SHOCK
WITH
CARDIOVASCULAR END-ORGAN DYSFUNCTION
11
Q
What type of shock does sepsis cause?
A
MIXED - CHOD:
-
Cardiogenic (defects of heart pump) - impaired cardiac function due to:
- hypovolaemia
- myocardial suppressive factors release by
- infective organisms
- host inflammatory response
-
Hypovolaemic
- loss of fluid
- fever
- D&V
- anorexia
- capillary leakage (increased vascular permeability)
- loss of fluid
- [[Obstructive (flow restriction)]]
-
Distributive (vessel abnormalities)
- altered vascular tone
- some vascular beds vasoconstricted, other vasodilated
-
Dissociative (inadequate oxygen releasing capacity of the blood)
- mitochondrial dysfunction impairs cellular oxygen utilisation
12
Q
Which age group has the highest incidence of sepsis?
A
Infants.
13
Q
What is the commonest cause of community acquired septicaemia in infants and children?
Name other common causative agents.
A
Neisseria meningitidis (meningococcus).
- GBS (infants)
- GAS
- Gram -ve sepsis (UTI/ gut problems)
14
Q
What sources of infection are important to consider in children with co-morbidities?
A
- neurological
- respiratory (impaired secretion clearance)
- long term indwelling devices e.g. catheters, PICC lines
15
Q
Describe the rash in meningococcal septicaemia.
A
- purpuric rash
- blanching erythematous rash (15%)
- replaces or
- precedes
- no rash (7%)
16
Q
Describe the clinical picture of TSS (top to bottom).
A
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
17
Q
Describe the emergency Mx of TSS.
A
- Fluids
- IVAB - CLINDAMYCIN (anti-staphyloccocal)
- IVIG
- Drainage of localised pus
18
Q
Describe the emergency management of septic shock.
A
- 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
- HYPODYNAMIC shock + HIGH SVR (COLD peripheries)
- ? 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
- 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
19
Q
Describe the emergency Rx of shock + meningitis with ICP.
A
- 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)
20
Q
What is anaphylaxis?
A
Potentially LIFE-THREATENING
IMMUNOLOGICALLY mediated rxn to
INGESTED/ INHALED/ TOPICAL substances
which may present as
SHOCK/ RESP DISTRESS.
21
Q
Name some common triggers of anaphylaxis.
A
- Food: nuts, fish, eggs
- Drugs: penicillin, Anaesthetic agents
- Radiographic contrast
22
Q
What blood test can be used to confirm the diagnosis of anaphylaxis?
A
Mast cell tryptase.
23
Q
What are life threatening features in anaphylaxis?
A
- DIB - stridor / wheeze
- Shock - vasodilation + increased capillary permeability = intravascular fluid depletion
24
Q
What are the signs of anaphylaxis?
A
- CV
- tachycardia
- hypotension
- poor pulse volume
- pallor
- cardiac arrest
- Resp
- wheeze
- stridor
- cyanosis
- resp arrest
- Skin
- urticaria
- angio-oedema
- conjunctivitis
- flushing
- sweating
- GI
- abdo pain
- nausea
- D&V
- Neuro
- agitation
- restlessness
- collapse
25
What signs in the history suggest severe allergic rxn?
1. Previous severe allergic rxn/ increasingly severe rxns
2. Asthma
3. B blockers
26
Describe the emergency Mx of anaphylaxis.
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
27
What does the ductus arteriosus connect?
The systemic and pulmonary circulations,
in fetal life.
28
Give examples of duct dependent pulmonary & systemic circulation & mixed.
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)
29
How do infants with duct-dependent pulmonary and systemic circulations present?
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
30
What are the signs of heart failure (top to bottom)?
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)
31
Describe the emergency Mx of congenital heart disease.
* 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 **S**YSTEMIC (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
32
How does the fetal circulation change in the neonatal period?
* 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
33
What can cause PPHN? (Peristent pulmonary hypertension of the newborn)
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
34
Describe the emergency management of shock secondary to cardiomyopathy.
How do they present?
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
35
What is defined as severe anaemia?
Hb \< 50
36
Describe the signs of severe anaemia caused by acute haemolysis (top to bottom).
* Skin: palms and soles near white
* Neuro: lethargic
* CVS: signs of heart failure
* Renal: urine dark brown
37
Name the most common situation in which children develop sudden severe haemolysis?
Name some other situations.
Most common:
1. HUS
2. sickle cell disease + sepsis
Other:
1. Malaria (severe anaemia with or without haemolysis)
38
What is HUS?
Describe the symptoms and causative agents.
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
39
Describe the emergency Mx of profound anaemia.
* TRANSFUSION if Hb \< 50
* heart failure?
* exchange transfusion
* diuretics
* sepsis?
* fluids +- inotropes
* IVAB
40
Decsribe the different types of sickle cell crises.
V .C A S H
1. **V**aso-occlusive
* Most common
* red cells clog small vessels
* tissue ischaemia
2. Acute **C**hest syndrome
3. **A**plastic crisis
4. **S**equestration crisis
* pooling of blood in the spleen and liver
* severe anaemia and hypotension
5. **H**yper-haemolytic crisis
41
What factors are thought to precipitate sickle cell crises?
I D . C A S H
* infections
* dehydration
* cold
* acidosis
* stress
* hypoxia
42
Describe the components of the emergency Mx of sickle cell crises.
* B
* O2
* C
* rehydration
* antibiotics
* analgesia incl. parenteral morphine (vaso occlusive crises & acute chest crises)
43
Is dextrose a suitable fluid for resuscitation? Why?
No.
Lowers sodium, predisposing to hyponatraemic seizures.
44
Which type of fluid should be used for resuscitation.
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
45
How does volume of fluid and rapidity of fluid resuscitation affect outcome in
(A) sepsis
(B) penetrating trauma requiring definitive surgical Mx
* Sepsis
* aggressive fluid resuscitation
* \> 40 ml/ kg in the first hour
* better outcome
* Penetrating trauma
* delay maximal fluid resuscitation until surgery
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
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
