4Stages in the management of a sick child (Ref. Chart 1, p. xxii) TriageEmergency treatment, if requiredHistory and examinationLaboratory investigations, if requiredDifferential diagnosesMain diagnosisTreatmentSupportive careMonitoringPlan dischargeFollow-up, if required
5What emergency (danger) and priority (important) signs do you notice from the picture? Temperature: 39.7ºC, pulse: 170/min, RR: 30/min,capillary refill 4 seconds. Cold hands and feet
6Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distressCentral cyanosisSigns of shockComaConvulsionsSevere dehydrationPriority signs (Ref. p. 6)Tiny babyTemperatureTraumaPallorPoisoningPain (severe)Respiratory distressRestless, irritable,lethargicReferralMalnutritionOedema of both feetBurns
9Emergency treatment (continued) Because of tachycardia, poor perfusion and cold extremities insert intravenous drip and give 20 ml/kgRinger’s lactate or normal saline solution(Ref. Chart 7, p. 13)
10Give emergency treatment until the patient is stable
11HistoryBaby Jone is a 6 month old boy, who was brought to the hospital with a two day history of fever, lethargy and decreased feeding. He had not been drinking well for about 2 days. He had vomited several times each day. His mother had taken his temperature and this registered 39.70C axillary. On arrival in the hospital he was lethargic.
12Examination Jone was lying with his eyes closed, but was rousable. Vital signs: temperature: 39.7ºC, pulse: 170/min, RR: 30/min, capillary refill: 4 seconds; cold hands and feetWeight: 7.0 kgChest: normal air entry both sidesCardiovascular: both heart sounds were audible and there was no murmurAbdominal examination: soft, bowel sounds were present; liver was palpable 1 cm below the right costal marginNeurology: lethargic, no neck stiffness, fontanelle normalMouth: slightly dry, no oral thrushEars: clear, no dischargeSkin: fine rash on trunk, arms and face
13Differential diagnoses List possible causes of the illnessMain diagnosisSecondary diagnosesUse references to confirm (Ref. p. 151)
14Additional questions on history Duration of feverFeeding pattern / vomitingConscious state – irritable / lethargicImmunization historyInfectious contactsMalaria endemic area
15Further examination based on differential diagnoses Look for signs of serious bacterial infection:Chest indrawingRash / skin sepsisStiff neck / fontanelle normal or bulgingEar-Nose-Throat examination
16What investigations would you like to do to make your diagnosis ?
17Investigations □ Discuss expected findings from investigations Blood glucoseUrine microscopy (and culture if available) (Ref. p. 185)“Clean catch” techniqueSupra-Pubic Aspirate (Ref. p. 350)Malaria microscopy of rapid diagnostic test (RDT)Lumbar puncture if signs suggest meningitisBlood culture if possible□ Discuss expected findings from investigations
18Full Blood examination Haemoglobin: 119 gm/l (125 – 205)Platelets: x 109/l (150 – 400)WCC: x 109/l (5.0 – 19.5)Neutrophils: x 109/l (1.0 – 9.0)Lymphocytes: 6.06 x 109/l (2.5 – 9.0)Monocytes: x 109/l (0.2 – 1.2)Blood sugar: 3.9 mmol/l (3.0 – 8.0)Malaria RDT: negative
23Treatment(Ref. p. 184)Ampicillin and gentamicin IV/ IM initially or a third generation cephalosporin, such as ceftriaxone. Consider complications such as pyelonephritis or septicaemiaGive parenteral treatment until fever subsides and/or urine culture results improve; switch then to an appropriate oral antibioticDepending on local sensitivity patterns different drug regime may be chosen
24What supportive care and monitoring are required?
25Supportive Care Fever management (Ref. p. 305) Nutritional management (Ref )Fluid management (Ref. p. 304)Give initially IV fluids because of signs of shock, but then reduce the rateEncourage regular breastfeeding
26MonitoringThe infant should be checked by nurses frequently (at least every 3 hours) and by doctors at least twice a dayUse a Monitoring chart (Ref. p. 320, 413)
27Follow up Investigate for renal abnormality Renal ultrasound if possibleRecheck platelet count to see if thrombocytopenia resolvesWatch for progression or resolution of petechial rash
28Summary Infant with systemic infection due to urinary tract infection Symptoms and signs often non-specificImportance of good history and examination, screening investigationsManagement of early shock, antibiotics, ongoing fluidsFrequent monitoringFollow-up