1. Case Scenarios

2. Case 1

3. 1.4 month old girl was brought to ED with a history of vomiting and diarrhea with poor oral intake. Child is looks sick and does not respond to her parents. Child is in respiratory distress. General Assessment 1.What is your initial impression of the child condition? Worrisome, child is sick with vomiting and diarrhea likely had viral GE and now hypovolemia due to fluid loss. Child appearance with decreased response suggest is in Shock. 2. Does this infant require immediate intervention, if so what? Yes, Provide oxygen and start immediate IV access. Call for help Airway, Breathing is adequate. Proceed to primary assessment and Start immediate fluid resuscitation with monitoring

4. Primary Assessment Child’s HR 200/min, RR 46/min, BP 60/40mm Hg Temp 97 0 F. Weak femoral pulses on palpation,extremitiies cool and motteled.CFT in foot is >5 seconds. Heart sounds are normal. Lungs clear on auscultation. During exam child moans occasionally. 3. How do you categorize this infant condition? Is the infant hypotensive? Vitals confirm that infant is in shock. Yes Lower limit of systolic blood pressure <60 mm Hg in infants during the first month of life <70 mm Hg for infants from 1 month to 12 months of age <70 mm Hg+ (2 ×age in years) for children from 1 month to 10 years of age

5. 4.What decisions and actions are appropriate at this time? Infant is in hypovolemic shock. Quick iv access and start iv fluid isotonic crystalloid solution bolus. If not able to get IV then try for IO. Do bedside glucose as soon as possible. 5.What is Shock? Clinical condition in which tissue perfusion is inadequate to meet the metabolic demand. 6.What elements of the secondary assessment would you like to know? SAMPLE Infant most likely has viral GE. Look for other signs, for a different cause of sepsis. See for rash, bruising. Assess abdomen

6. Additional History S - child has continuous vomiting and diarrhea from past 10 hrs, uncertain about urine output Allergy- No Medications- No Past medical history- Unremarkable Last meal- one ounce of fluid an hour ago Events leading started with vomiting then later diarrhea started. And now diarrhea worsened. Infant has reduced skin turgor. Abdomen soft with liver at coastal margin. Her fontanel is sunken

7. 7.What would you do know? Put IV line, if expert is available to put CVO can be tried. Most appropriate next step is IO 8.After IV access, what and how much fluid would you give. How quickly you administer the fluid. What bedside lab test is critically important? 20 ml/kg of isotonic fluid i.e normal saline. As rapidly as feasible, ideally less than 15 min. Blood glucose test.

8. Bed side glucose is 40mg/dl. You give fluid bolus of isotonic crystalloid and a bolus of dextrose. Infant appears a bit responsive, Still distal pulses are weak. CFT remains prolonged. 9.What would you do know? She showed slight improvement but still distal pulses are weak. These indicate that another fluid bolus is indicated. 10. What additional tertiary studies would you like to obtain? Repeat Blood glucose, Serum Electrolytes, CBC, Urine analysis, Blood and urine cultures.

9. Infant receives additional fluid. Infant appears more responsive and distal pulses are now palpable.Lab studies showed sodium 132 mEq/L, Potassium 3.9 mEq/L, Chloride 106 mEq/L, BUN 26 mg/dl, creatinine 0.9 mg/dl and lactate 4.2 mmol/L. WBC 7600/mm 3 and Hb is 10.8 gm%, Hct 33% and platelet count is 335000/mm 3. Repeat bedside glucose is 50 mg/dl. 11.How does the lab data help you categorize this infant condition? Normal white count and platelets will suggest infant does not have bacterial sepsis. 12. What are your decisions and action now? As blood glucose is low give another bolus of glucose and start maintenance iv glucose solution. As electrolytes are normal, Normal saline or ringer lactate will be appropriate.

10. Case 2

11. A Mother brings her 4 year old girl child with a history of increasing lethargy, fever and dizziness. No history of vomiting and diarrhea. Her intake has been poor over the last 12 hrs. Typical chickenpox lesions developed 5 days ago. Over the last 18 hours several lesions on her abdomen have become red, tender and swollen. General Assessment AS you enter check vitals, you note that child is lying supine and appear listless. She is breathing rapidly and skin is mottled 1. What is your initial impression of the child condition? Does this child need immediate intervention, if so what? Very worrisome, as child has decreased response to surrounding environment, With the history of chicken pox and these changes indicate child may be in sepsis. Yes child needs immediate emergency care activate ERS to treat shock and stabilize the child. Start oxygen, has to be provided in all children with shock to improve oxygen delivery to tissues. Any child suspected with shock complete primary assessment, connect to cardiac monitor and pulse oximeter. Put IV cannula and give rapid bolus and then do clinical reassessment.

12. Primary Assessment Call for help and start oxygen, Attach pulse oximeter and cardiac monitor. You note that child is confused, she does not recognize the place and does not seem to understand what people are saying. Her HR 160/min, RR 60/min, rectal temp 103 0 F, BP 90/30 mmHg. Clear lungs with regular rapid heart beat with a systolic ejection murmur. Extremities are warm and bright red. Central pulses are bounding peripheral pulses are palpable but feel thready. CRT is about 2 seconds. Spo2 is of 100% while child is on O 2. 2.How do you categorize this child condition? What decisions and actions are indicated now? Tachycardia with adequate distal perfusion and an acceptable systolic BP. These findings consistent with compensated septic shock. As soon as possible IV cannula is established, administer a rapid bolus of NS or RL and then do reassessment.

13. 3. What is the significance of the pulse pressure and the elevated respiratory rate? One of the characteristic feature of sepsis is wide pulse pressure. Increased RR representing a compensatory response to create a respiratory alkalosis to counteract the metabolic acidosis that characterize the shock. 4. What other conditions result in wide pulse pressure? In addition to septic shock, it is seen in Anaphylactic and Spinal shock. Significant Anemia High Fever 5. What additional studies indicated? During Secondary assessment, look for evidence of Cardiac Dysfunction ( Gallop, Venous distension in neck, Hepatic size ) Purpura and petechia for DIC or other coagulopathies Focused Medical History S A M P L E Blood Glucose test. Serum Electrolytes, Blood Culture, Blood counts.

14. After IV access, You administer an isotonic crystalloid fluid bolus of 20ml/kg. your repeat assessment reveal HR150/min, RR still 60/min, BP 85/30 mmHg. Still distal pulses are weak with a CRT <2 sec. skin is warm to the wrist and ankle. Mother report that child’s dizziness started about an hour ago (S) No history of Allergy She received acetaminophen for fever (M) Child was healthy up until this recent illness of chickenpox (P & E) 6.What would you do now? Repeat assessment shows a slight improvement in child’s HR. Monitoring the change in HR is an important element of shock. Frequent reassessment and aggressive fluid resuscitation are commonly required.So child requires another rapid bolus with NS or RL Fallowed by clinical reassessment. If available administer appropriate antibiotics.

15. You administered a second bolus, bed side glucose is 140 mg/dl. Child is shifted to health care. In response to second bolus child become alert. Blood cultures are obtained and IV antibiotics are given along with another 20ml/kg bolus. Despite fluid bolus the child condition deteriorates. She becomes unresponsive to voice and barely responsive to painful stimulation. Her distal pulses are no longer palpable, extremities are cold. Her HR ranges from 170 to 180/min, her BP decreases to 70/25 mmHg. She remains tachypneic on oxygen, lungs remain clear but pulse oximetry is not picking up her pulse accurately. 7. How would you categorize the child condition now? What decisions and actions are indicated? Despite a total of 60ml/kg in 3 boluses in less than an hour, this child SBP indicates that she has Hypotensive shock that is fluid refractory. Establish central line to safely administer a potent vasoconstrictor such as norepinephrine, high dose dopamine or vasopressin. If central line cannot be established, a secure peripheral IV or IO line may be used. This require second access site because fluid boluses should not be given through the same site as the vasoactive drug.

16. 8.Why she is deteriorating despite fluid administration? Child has vasodilated septic shock. Sepsis is a form of distributive shock because it is characterized by a maldistribution of blood flow. venodilatation results in pooling of blood in venous circulation with reduced venous return and reduced cardiac output. Increased capillary permeability contributes to relative hypovolemia despite fluid administration. 9.When would you add vasoactive drug support? If patient does not respond to aggressive fluid resuscitation then we need of vasoactive drugs. Potent vasoconstrictor agents may be helpful to maintain effective perfusion of the Brain and Heart. 10.What are the indications for giving “stress dose” corticosteroids? If the child requires potent vasoactive agents, many recommend the addition of a stress dose of hydrocortisone-typically only 2mg/kg as a loading dose.

17. Case 3

18. A 3 month old girl is brought to the ED with history of poor feeding and listless behaviour that was worsened from over the past hours. She had vomiting and diarrhea for several days which was resolved. She is not taking orally well. General Assessment Infant appears listless, breathing rapidly with mild to moderate retractions. Color appears mottled. 1.What is your initial impression of the child condition? Does this child need immediate intervention to treat a life threating condition, if so what? There is a poor perfusion, altered mental status and increased work of breathing. Yes Start oxygen and activate ERS, Place the infant on a cardiac monitor and pulse oximeter.

19. Primary Assessment Call for help and start oxygen, Attach pulse oximeter and cardiac monitor. Her HR 220/min with a regular rhythm, RR 50/min, temp 97 0 F, BP 55/40 mmHg. Infant has little response to verbal on painful stimulation. There is increased respiratory effort with mild retractions. On auscultation reduced distal air entry and inspiratory moist crackles at both lung bases. Cardiac rhythm is rapid without murmur. Distal pulses are not palpable. Extremities are cool and mottled below elbow and knees. CRT in foot is >6 sec. 2. How do you categorize the infant’s condition now? Infant has hypotensive shock 3. What are your decision and actions now? Urgent administration of high floe oxygen and rapid establish IV access. The severity of the condition is not consistent with the history. The 2 common types of shock with more severe form are septic and cardiogenic. The narrow pulse pressure is more consistent with cardiogenic shock rather than septic shock, especially since there is an increased work of breathing with moist bilateral crackles. A fluid bolus of 5-10ml/kg is indicated with possibiltyof cardiogenic shock and then reassess

20. After IV fluid bolus of Isotonic crystalloid, Repeat exam and a focused history Recent illness began with vomiting and diarrhea(S) No Allergies, Not on any Medications Past history is unremarkable Events – Vomiting lasted for a day and she had 5-6 loose bowel movements a day. After fluid bolus infant has increased work of breathing and grunting respiration. Moist crackles remain bilaterally. Her HR is 220/min, RR 55/min, BP 60/45 with no improvement in her pulses. Spo2 is 95% on 100% oxygen. Infant liver is firm and palpable 3cm below the coastal margin. Bed side glucose is 80mg%. 4.What do you think is happening? Why is there no improvement after the fluid bolus? History of prior GE suggest an Acute viral Myocarditis in view of the poor response to a fluid bolus. This infant appeared to have GE, but the response to fluid suggest that the diagnosis is incorrect. Instead the likelihood of cardiogenic shock is increased considering the described response.

21. 5. What are your decisions and actions now? This infant require urgent intervention to improve cardiac output and support adequate oxygenation and ventilation. Infant with hypotensive cardiogenic shock the first priority is to increase the BP to provide adequate perfusion to the heart and brain. In a short term an inotropic and vasopressor agent such as epinephrine may be started. 6. What lab and radiographic studies would be helpful now? Serum glucose For end organ dysfunction evaluation- BUN, Creatinine, LFT. Chest X-ray: Cardiac size, pulmonary edema ECG: Arrhythmia ECHO: Cardiac function and heart size.

22. After a femoral venous line, lab studies sent. Venous blood gas was pH 7.25, pCo2 39, pO2 23, HCo3 13, base deficit-10.5, oxygen saturation 44%, Lactate is 7.5 mmol/L. WBC, Platelet count and Hb are Unremarkable. Sodium 135mEq/L, Potassium 4.4 mEq/L, Chloride 97mEq/L, BUN 23mg/dl, Creatinine 1.1 mg/dl. Chest xray shows bilateral diffuse alveolar infiltrates with an increased cardiac silhouette size. ECG shows a narrow complex tachycardia with small QRS complexes. 7. How do you interpret the lab data? Venous bllod gas confirms the presence of a significant metabolic acidosis with an increased lactate.the low venous oxygen saturation indicate increased oxygen extraction because of low cardiac output and tissue oxygen delivery. The elevated BUN and creatinine are evidence of renal dysfunction, most likely due to inadequate renal perfusion Chest xray confirms an enlarged heart size ECG is consistent with myocarditis( Small QRS complexes)