1. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. SCENARIO CASE 1

2. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. History A 7 year old child presents with a 6 hour history of sore throat, fever, and headache. The general practitioner has attended, noted "delirium", and called for an ambulance. The child has been previously well.

3. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Initial Impression Respiratory rate 48, pulse 180 bpm with reduced capillary refill, blood pressure 90/60, responding only to painful stimuli. Guide weight 22 kg.

4. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Additional History and Observations There is a fever (38.6 oC) and a few petechiae are noted on the trunk.

5. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Diagnosis Meningococcal septicaemia

6. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Clinical Course There is no improvement in the clinical condition of this patient until the third fluid bolus, respiratory parameters deteriorate until intubation is performed and ventilation commenced. The child then stabilises.

7. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Key Treatment Points AirwayEstablish airway patency BreathingHigh flow O2 via face mask Orotracheal intubation & ventilation Circulation IV/IO access Fluid boluses Commence inotropes Specific Therapy IV Antibiotics

8. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. SCENARIO CASE 2

9. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. History A 4 month old baby is brought to hospital because he is breathing rapidly. He has been hot and restless, has vomited twice, and passed 2 loose stools. Now he is refusing to take a bottle and appears pale and listless.

10. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Initial Impression Respiratory rate 65, pulse 160, capillary refill time 6 seconds. He has pale, mottled peripheries and is uninterested in his surroundings.

11. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Additional History and Observations His temperature is 39oC. Peripheral pulses are not palpable. BP is 70 systolic. Glucose stick test < 5mmol/l. Guide weight 5kg.

12. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Diagnosis Septicaemia

13. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Clinical Course The baby's condition remains unchanged until 40ml/kg fluid are been given. Capillary refill time then improves and peripheral colour returns. If oxygen is not administered this improvement does not occur. If a glucose stick test is not performed the child may fit because of hypoglycaemia.

14. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Key Treatment Points AirwayEstablish airway patency BreathingHigh flow O2 via mask Circulation IV/IO access Fluid boluses Specific Therapy IV antibiotics

15. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. SCENARIO CASE 3

16. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. History A 7 year old girl is brought into the Emergency Department by her mother who has noticed that she has become sleepy and has laboured breathing. 24 hours previously she had been seen at another hospital with abdominal pain. A diagnosis of constipation was made.

17. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Initial Impression Snoring respirations with a respiratory rate of 30 and deep acidotic breathing. Pulse is 160 with poor volume. Capillary refill is 5 seconds. She responds to her mother's voice by briefly opening her eyes. Guide weight 22 kg.

18. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Diagnosis Diabetes mellitus in ketoacidotic coma

19. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Clinical Course She is shocked and 15% dehydrated. Blood glucose is 32 mmol/l, pH 7.03, PaO2 23.1 kpa on oxygen, PaCO2 2.5 kPa, potassium 6 mmol/l. Pulse volume improves and capillary refill shortens after the second fluid bolus. She does not become fully alert but willrespond to questioning after this treatment.

20. 28/02/2011 N-PICU Mahosot Hospital SOUMPHONPHAKDY Bandith. Key Treatment Points Airway Establish airway patency Airway opening manoeuvres BreathingHigh flow oxygen by face mask Circulation IV access Appropriate blood tests Fluid bolus x 2 Specific Therapy Assess dehydration Calculate deficit Begin normal saline replacement Insulin infusion Monitor for cerebral oedema