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Pediatric Septic Shock: Recognition and Management in the Emergency Department
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Publication Date: November 2022 (Volume 19, Number 11)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 11/01/2025.

Authors

Ara Festekjian, MD, MS
Associate Professor of Clinical Pediatrics, Children’s Hospital Los Angeles, Division of Emergency Medicine and Transport, Los Angeles, CA
Julia Glavinic, MD
Emergency Department, Riverside, CA

Peer Reviewers

Julia K. Lloyd, MD
Assistant Professor of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
Louis A. Spina, MD
Assistant Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Abstract

Sepsis is a leading cause of mor­bidity and mortality in children. Early recognition and timely initiation of empiric broad-spectrum antibiotics and crystalloid fluid administration have been as­sociated with better outcomes. Although evidence for diagnosis and treatment of septic shock was first generated in adult studies, it is clear that pediatric studies are needed for management of septic shock in children. This issue provides guidance for managing septic shock in children, with a focus on early recognition and appropriate resuscitation.

Case Presentations

CASE 1
An 8-year-old boy is brought in by his parents for fever, redness to his left shin, vomiting, and diarrhea...
  • The boy’s parents tell you he scraped his shin 5 days earlier while playing at a park. His shin became progressively red and hot. He has had fever with vomiting and diarrhea for 3 days. He started to seem unusually tired, prompting their visit to the ED.
  • On examination, the boy is lethargic, with shallow respirations. His vital signs are: temperature, 38.9°C; heart rate, 176 beats/min; respiratory rate, 35 breaths/min; and blood pressure, 80/57 mm Hg. After an initial response to bag-valve mask ventilation, the patient's mental status again deteriorated.
  • If the patent needs an advanced airway, what medications should you choose to secure his airway? What are the possible consequences of initiating rapid sequence induction?
CASE 2
A 2-year-old boy with a history of short-bowel syndrome presents with fever and fatigue for 1 day…
  • The boy’s short-bowel syndrome is secondary to necrotizing enterocolitis, and he has total parenteral nutrition dependence. He was well 1 day prior and started to have loose stools on the day of presentation. His temperature at home was 38.7°C axillary, and he received a 15 mg/kg dose of acetaminophen en route to the ED.
  • The boy’s presenting vital signs are: temperature, 37.8°C; heart rate, 176 beats/min; respiratory rate, 28 breaths/min; blood pressure, 97/42 mm Hg; and oxygen saturation, 95% on his home 0.5 L/min oxygen. He seems tired and is noted to have bounding radial pulses.
  • You immediately suspect septic shock based on his fever, fatigue, central line, tachycardia, tachypnea, and bounding pulses. Which antibiotics would be best for this patient? If vasoactive support is needed, which agents should be used first?
CASE 3
A 16-year-old girl with a diagnosis of leukemia presents after a syncopal episode...
  • The girl recently completed induction chemotherapy. She was at her routine hospital discharge follow-up visit and had a syncopal episode while walking to the restroom. She has normal mental status, denies fever or vomiting, and reports still feeling dizzy when walking, despite drinking several bottles of water prior to the ED visit.
  • The laboratory values obtained from her portacath during her clinical visit do not reveal neutropenia, and her hemoglobin is 10.2 g/dL, with normal electrolytes and a negative pregnancy test. Her vital signs are as follows: temperature, 37.6° C; heart rate, 110 beats/min; respiratory rate, 22 breaths/min; blood pressure, 110/72 mm Hg; and oxygen saturation, 99% on room air.
  • What is the cause of her syncope? Why does she remain dizzy?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

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