SARAH Author: Steve Miller, M.D., Columbia University Learning Objectives Students will be able to describe: How to determine if a patient is emergently ill. 1. The differential diagnosis of a lethargic child. 2. The different types of shock. 3. The actions needed to perform the ABCs. 4. The principles of choosing the right fluids. 5. The principles of effectively breaking bad news to a patient and a patient's parents. 6. The principles of phone triage. 7. Summary of clinical scenario: The father of 15-year-old Sarah calls concerned because she has a fever of 103 Fahrenheit and is out of it. He also says she is breathing pretty fast, and looks pale. She has not had anything to eat or drink all day and has not urinated since early in the morning. Her father is advised to bring Sarah into the emergency department. En route to the hospital in the ambulance, Sarah develops a petechial rash on her trunk and arms. Physical exam reveals nuchal rigidity, along with tachycardia and decreased perfusion. Sarah is given boluses of intravenous fluids and parenteral antibiotics for meningococcal sepsis. Key Findings from History Rash Lethargy Tachypnea Decreased urine output medU | Instructors http://www.med-u.org/communities/instructors/clipp/case_sum... 1 of 7 4/4/12 1:16 PM Key Findings from Physical Exam Petechial rash Tachycardia Nuchal rigidity Differential Diagnosis Hypoglycemia Poisoning Diabetic ketoacidosis Central nervous system tumor Meningitis Renal failure Encephalitis Pneumonia Sepsis Key Findings from Testing Gram stain positive for gram-negative diplococci, consistent with meningococcus Final Diagnosis Meningococcemia Case highlights: The case teaches when and how to triage over the phone, and what information to gather before advising a patient to be seen in the emergency department. Once Sarah arrives at the hospital, the case focuses on how to determine level of consciousness, assess airway, breathing, and circulation, and determine if a patient is in shock. Students learn how to manage a patient in shock and how to administer fluids to maintain perfusion. Having determined that Sarah has meningococcemia, students learn how to treat the disease and how to break the bad news to her parents. Multimedia features include photographs and drawings illustrating how to open a childs airway. Key Teaching Points Knowledge Shock: Definition: Inadequate delivery of substrates and oxygen to meet the metabolic needs of tissues.In the pediatric age group, shock is not a blood pressure diagnosis; children can maintain a normal blood pressure until they are in profound shock. Compensatory mechanisms: Children in shock have excellent compensatory mechanisms to maintain tissue perfusion, including: medU | Instructors http://www.med-u.org/communities/instructors/clipp/case_sum... 2 of 7 4/4/12 1:16 PM Increased heart rate (tachycardia): When stroke volume decreases, the body tries to maintain cardiac output by increasing the heart rate. Increased systemic vascular resistance (vasoconstriction) Increased heart contractility (more complete emptying of the ventricles) Increased venous tone (greater blood return to the heart) Increased respiratory rate (tachypnea): The bodys attempt to compensate for the metabolic acidosis caused by decreased oxygen perfusion of the tissues and cells. Types: Hypovolemic and septic shock are most common causes of shock in children. Hypovolemic shock: Inadequate fluid intake to compensate for fluid loss (e.g., vomiting, diarrhea, hemorrhage). Signs and symptoms: Mental status changes, tachypnea, tachycardia, hypotension, cool extremities, oliguria. Septic shock: Infectious organisms release toxins that affect fluid distribution and cardiac output. May be bacterial, viral, orin immunocompromised patientsfungal. Patient needs repeated boluses of fluid. May need inotropes to enhance cardiac contractility and vasopressors (epinephrine or dopamine) to raise blood pressure. Signs and symptoms: May present initially as compensated or warm shock (warm extremities, bounding pulses), tachycardia, tachypnea, adequate urination, mild metabolic acidosis Cardiogenic shock: Rare in children; may be associated with severe congenital heart disease, dysrhythmias, cardiomyopathy, or tamponade. Signs and symptoms: Cool extremities, delayed capillary refill (> 2 seconds), hypotension, tachypnea, increasing obtundation, decreased urine output Distributive shock: Includes neurogenic shock and anaphylactic shockwhere vasodilation, increased capillary permeability, and third-space fluid loss results in intravascular hypovolemia. Skills Principles of telephone triage: It is highly risky to offer advice over the telephone to a patient not known to the physician. Even if the physician does know the patient, caution must be used. Keep these guidelines in mind: As a student or resident, never give phone advice on your own without supervision from an attending. Let the patient or parent know that a physician will see the patient in the office the next day, or that the staff in the emergency department can see the patient immediately, but that no medical decisions can be made about a patient who has not been seen. You may answer follow-up questions from a patient or patients parent whom you have seen previously if the questions are about the same problem (e.g., how long do I need to keep my child on his medications; is medU | Instructors http://www.med-u.org/communities/instructors/clipp/case_sum... 3 of 7 4/4/12 1:16 PM he contagious, etc.). If the family calls and asks about a new problem or condition, then the same rules apply as if this was a patient you had never seen before. If advice is given, it must be documented. Criteria for recommending immediate medical attention: Consider a patient to be dangerously ill if the vital life functions of delivering oxygen and nutrients to end organs are impaired. Assess functioning of the brain, skin, kidneys, and lungs. Also determine if there are underlying conditions that place the patient at risk (e.g., sickle cell disease, human immunodeficiency virus, neutropenia, diabetes mellitus). Always start with the ABCs: It is essential to look first for anything that reduces oxygen and critical nutrients to cells: Airway: If patient does not seem to be moving air with breathing, first check the airway and determine if there is an obstruction. May need to: Position the neck Perform a jaw thrust (if concern about head trauma) Breathing: Observe effort and rate of breathing, how the patients lungs sound, and if they are well oxygenated: Look at the chest to determine the respiratory rate. Listen to breath sounds for wheezes, rales, rhonchi, diminished breath sounds. Use a pulse oximeter to rapidly assess the oxygenation of the patient (may be difficult due to vasoconstriction) Circulation Tachycardia is first and most subtle sign of possible inadequate perfusion. Check capillary refilla sensitive sign of hypovolemia. In reality, the ABCs also include a "D" and "E: Disability and Dextrose Disability: A quick neurologic assessment to uncover signs of increased intracranial pressure or possible poisoning: Assess mental status. Examine pupils, including their size and reaction to light. Pupillary changes, especially unequal pupils, are a sign of increased intracranial pressure. May find a clue to a toxidrome (such as lethargy and pinpoint pupils, suggesting opioid ingestion). medU | Instructors http://www.med-u.org/communities/instructors/clipp/case_sum... 4 of 7 4/4/12 1:16 PM Dextrose: This is a reminder to check for hypoglycemia, a condition that must be diagnosed and treated immediately. Exposure and Environment: Expose and examine all parts of the patient, and keep the patient warm during the evaluation Giving bad news: Make sure the patient and family are comfortable and have support people with them. Ask what the patient or parent knows and what their concerns are. Tell them the diagnosis and what the treatment is without using medical jargon. Tell them the prognosis. Be honest and give some way to offer hope. If the situation is bleak, give the patient and family short-term goals and tasks. Differential diagnosis Altered mental status or lethargy in a child: Meningitis: Fever in child with altered mental status highly suggestive of meningitis. Tachypnea and decreased urine output consistent with associated shock. Hallmark symptoms of meningitis are fever, headache, stiff neck, altered mental status, and photophobia (although many patients present with only two or three of these clinical indicators). 1. Sepsis: Fever and lethargy are prominent symptoms with sepsis. Tachypnea and decreased urine output are also commonly seen. 2. Diabetic ketoacidosis (DKA): Patients in DKA can present with lethargy and tachypnea. Urine output would be increased, not decreased. 3. Renal failure: Associated acidosis could lead to tachypnea and lethargy. May be primary or secondary (i.e., due to another etiology). 4. Ingestion: Overdoses can often cause otherwise unexplained lethargy. Depending on toxin, decreased urine output and tachypnea may be seen. 5. Central nervous system (CNS) tumor: Increased intracranial pressure due to mass effect from a CNS tumormay lead to lethargy and tachypnea. 6. Hypoglycemia: Low blood sugar may cause lethargy and altered mental status. 7. Encephalitis: Often caused by viral infections in children. Presents with altered mental status and fever. 8. Pneumonia: Fever and tachypnea would be found with pneumonia, but altered mental status would be uncommon unless patient was severely hypoxic. 9. Petechial rash, fever, lethargy, and shock: Meningococcal sepsis: Whenever a patient presents with fever and 1. medU | Instructors http://www.med-u.org/communities/instructors/clipp/case_sum... 5 of 7 4/4/12 1:16 PM petechiae, meningococcal sepsis must always be at the top of the differential diagnosiseven if the patient otherwise looks well. A blood culture must be collected and antibiotics given until the disease can be definitively ruled out. The fatality rate in all ages is 10%, 25% in adolescents. Sequelae, occurring in 1119% of patients, include hearing loss, neurologic disability, digit or limb amputations, and skin scarring. Kawasaki disease: Fever and rash are associated signs. Mucocutaneous lesions include a "strawberry" tongue and dry, red, cracked lips. There is diffuse erythema of the oral cavity and erythema and/or edema of hands/feet and a polymorphic truncal rash. 2. Toxic shock syndrome: Cause of fever and a sunburn-looking rash that might feel rough to the touch (like sandpaper). 3. Scarlet fever: This starts as a finely punctate pink-scarlet exanthem that appears on the upper trunk 1248 hours after onset of fever. As rash spreads to the extremities, it becomes confluent and feels like sandpaper. Linear petechiae (Pastias sign) are evident in body folds. Pharynx is beefy red and the tongue is initially white and rough (strawberry tongue), later becoming bright red. 4. Studies Complete blood count (CBC) with differential and platelets, blood/urine culture,and gram stain: These are needed to rule sepsis in or out as soon as possible. Also, blood and urine cultures must be obtained before starting antibiotics. Chemistries (sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, glucose): Hypoglycemia and other electrolyte imbalances are common causes for altered mental status. Their levels must be checked. Lumbar puncture: Obtain once patient is stabilized. Management Initial emergency management of shock Intravascular volume replacement is the priority, even when there is a risk of increased intracranial pressure. In most patients, a fluid bolus of 20 cc/kg normal saline should be given rapidly via intravenous or intraosseous line. Replace fluid volume replacement with isotonic saline, not hypotonic. If patient continues to have poor perfusion and shock after fluid resuscitation, may need vasoactive agents. Reference: Behrman RE, Kliegman RM, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics, 18th Ed. Philadelphia, Pennsylvania. 2007 medU | Instructors http://www.med-u.org/communities/instructors/clipp/case_sum... 6 of 7 4/4/12 1:16 PM Indications for intraosseous (IO) access: In an emergency, if a peripheral intravenous line cannot be placed within 90 seconds, an IO line (via a needle inserted into the marrow cavity of a long bone) should be placed. This provides fast and easy access for any fluid. Substances injected into the marrow are absorbed almost immediately into the general circulation. Placing a central line (femoral, subclavian, internal jugular) takes longer than an IO, but may be acceptable in older child, adolescent, or adult. Arterial line: Arteries cannot tolerate the massive fluids required for resuscitation. Antibiotics: The most appropriate antibiotic treatment for meningococcemia is penicillin G. Calculating doses for teenagers and large children can be tricky. Doublechecking calculations with the formulary is an important step to preventing mistakes when prescribing medications. Infection control: Household, childcare, and nursery schoolcontactsand any health care workers having close contact with the patient before she/he received antibioticsshould receive prophylaxis (ciprofloxacin for adults and rifampin or ceftriaxone for children). Immunization: For the general population, the tetravalent meningococcal conjugate vaccine (MCV4) is given intramuscularly to children ages 1118, usually at the routine preadolescent visit. A booster dose should be given at age 16, before the peak in increased risk. (Adolescents who receive their first dose of MCV4 at or after age 16 years do not need a booster dose.) College freshmen living in dorms are considered high risk and should receive a dose of the MCV4 vaccine within 5 years before starting college. The MCV4 vaccine is not recommended for children < 2 years of age. There are guidelines for certain other situations in high-risk children and adults in which administration of MCV4 is recommended. Back to Top Copyright 2012 iInTIME. All Rights Reserved.
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