In the pediatric office, the big key to managing pediatric sepsis and pediatric septic shock is to recognize it (just as it is in pediatric diabetic ketoacidosis). Once we have recognized the problem we will transfer the patient to the emergency department. That said, careful review of the notes of Reference (1) below, will allow us to recognize the problem rather than missing it and sending the patient home. And References (2) and (3) should be reviewed also as all three of the references each cover different aspects of the recognition and management of serious pediatric infections (and all three references are brought to us by the outstanding Emergency Medicine Cases).
And we need to be ready and able to place an intraosseus line in the patient with pediatric uncompensated septic shock if we have been unable to place a peripheral IV within two attempts and/or within one minute (because the pediatric patient in uncompensated shock is pre-arrest).
Also we want to never forget to check any sick child’s glucose: A-B-C-D-E-F-G meaning A-B-C-Don’t Ever Forget Glucose.
To recognize pediatric sepsis early we need to be alert for any unexplained tachycardia and we need to know the normal pediatric vital signs by age.
And finally when we diagnose pediatric sepsis in the office or urgent care we want to promptly give parenteral antibiotic – ceftriaxone [However, ceftriaxone is “contraindicated in neonates with hyperbilirunemia” Reference (4)].
Reference (1) is an outstanding podcast and show notes for pediatric sepsis and septic shock from Emergency Medicine Cases. The podcast is incredibly helpful. Here are some notes from the post:
Pediatric Sepsis
Sepsis in children is a relatively rare emergency department presentation. Although only about 0.35% of pediatric emergency department visits are for sepsis, the mortality rate is as high as 2 to 10% (1,2). Having a sepsis guidelines protocol in the emergency department can decrease mortality from 5% to as low as 1% (2)
Red Flags in the Recognition of Pediatric Sepsis
- Age: <1yr and early adolescence (10-14yr). (Bimodal distribution)
- Of the children <1yr, most will be <1month old (high risk)
- Unexplained tachycardia (after correcting for fever – see below)
- Clinical signs:
- Poor perfusion (long cap refill, lethargy, irritability)
- Conditions that predispose to sepsis: neuromuscular disease, immunocompromised, respiratory conditions, cardiac disease
- Recent surgery
Temperature Corrected Heart Rate and Respiratory Rate**Recall from podcast 48, rule of thumb – Heart Rate increases by approximately 10 beats/min and Respiratory Rate by 5 breaths/min for every Celsius degree (1.8 degree of Fahrenheit) of fever >38°C
For example, if the temperature is 40°C and HR 144 -> subtract 2×10 -> corrected HR 124
If the child has tachycardia after being corrected for fever, consider other contributors (pain, crying, early compensated shock). Check perfusion, ask about urine output, and have a high degree of suspicion for dehydration and sepsis.
Age Heart Rate (beats/min) Blood Pressure (mm Hg) Respiratory Rate (breaths/min) Premie 120-170 55-75/35-45 40-70 0-3 mo 100-150 65-85/45-55 35-55 3-6 mo 90-120 70-90/50-65 30-45 6-12 mo 80-120 80-100/55-65 25-40 1-3 yr 70-110 90-105/55-70 20-30 3-6 yr 65-110 95-110/60-75 20-25 6-12 yr 60-95 100-120/60/75 14/22 12 > yr 55-85 110-135/65/85 12-18 Hypotension is a Late Sign of Pediatric Septic Shock
- Be very cautious in setting of tachycardia and DO NOT WAIT for hypotension to make diagnosis of septic shock.
- A pediatric patient with hypotension and sepsis is a pre-arrest patient.
Investigations in Sepsis
Blood work should include CBC, electrolytes, glucose, kidney function, blood gas, blood cultures, LFTs, and lactate. Urine cultures are commonly done to identify a possible source. Clinical history guides imaging such as chest x-ray.
ABC – DEFG = ABC, DON’T EVER FORGET GLUCOSE
Up to 25% of children with septic shock will have adrenal insufficiency, so always check glucose in septic children. Extremes in blood glucose in sepsis are associated with higher mortality in children (2). Arterial lactate 2 times upper limit of normal indicates organ dysfunction.
Please note that the above is only the first part of an incredibly helpful set of the show notes and you need to review the complete set of notes at the site and listen to the podcast more than once [it is tremendous].
And be sure to listen to and review Reference (2) Best Case Ever 27: Pediatric Shock also from Emergency Medicine Cases. [Links below]
And finally, listen to and review Reference (3) Best Case Ever 27: Pediatric Shock also from Emergency Medicine Cases. [Links below]
Resources:
(1) Episode 50 Recognition and Management of Pediatric Sepsis and Septic Shock from podcast and blog Emergency Medicine Cases, [link to show notes and podcast]:
Kids aren’t little adults. Pediatric sepsis and septic shock usually presents as ‘cold shock’ where as adult septic shock usually presents as ‘warm shock’, for example. In this episode, a continuation of our discussion on Fever from with Ottawa PEM experts, Sarah Reid and Gina Neto, we discuss the pearls and pitfalls in the recognition and management of pediatric sepsis and septic shock. We review the subtle clinical findings that will help you pick up septic shock before it’s too late as well as key maneuvers and algorithms to stabilize these patients. We cover tips for using IO in children, induction agents of choice, timing of intubation, ionotropes of choice, the indications for steroids in septic shock, and much more…..
(2) Best Case Ever 27: Pediatric Shock from the podcast and blog Emergency Medicine Cases, [link to show notes and podcast]
(3) Episode 48 – Pediatric Fever Without A Source from Emergency Medicine Cases, [Link to show notes and podcast]
(4) The Harriet Lane Handbook, Twentieth Edition, Elsevier Saunders, 2015. Formulary: Ceftriaxone, p. 724.
(4) Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, [Full Text HTML] [Full Text PDF]
Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [Full Text HTML] [Full Text PDF]
