Emergencies Flashcards
Define sepsis
Definition: a clinical syndrome resulting from a dysregulated immune response to infection.
o Bacteria may cause a focal infection or proliferate in the bloodstream → where the host response including release of inflammatory cytokines and activation of endothelial cells may lead to sepsis
Describe the normal immune response, how does it differ to sepsis?
The normal host response to infection is an inflammatory process aimed at controlling the infection
o Triggered when innate immune cells recognise invading pathogen
o These cells secrete pro-inflammatory cytokines
o This causes vasodilation and vascular permeability (capillary leak)
o In normal host response, this pro-inflammatory response is regulated and localised by a simultaneous anti-inflammatory response
o Sepsis occurs when this normal pro-inflammatory response exceeds its homeostatic constraints causing inflammation remote from the infection source
What are the commonest organisms found in children in the UK from blood cultures?
- Staphylococcus aureus
- non-pyogenic Streptococci
- Streptococcus pneumoniae (pneumococcus)
What gram -ve bacteria can be found in sepsis?
- Neisseria meningitides (meningococcus)
- E. coli
What sepsis causing bacteria are declining due to immunisations?
- H. Influenzae type B
- Meningococcus
- Pneumococcus
What bacteria are found in neonates causing sepsis?
- Early-onset
- group B streptococcus
- E. coli
- Late onset: coagulase-negative staphylococcus (CoNS) or S.epidermidis
- S.epidermidis can be found in childhood but mostly always a skin contaminant
Who is at higher risk of sepsis?
Children with underlying health conditions, indwelling catheters and immunodeficiency are at higher risk of infection progressing to sepsis.
What could happen if sepsis is not identified early?
If not identified and treated quickly, sepsis can rapidly result in septic shock, with multiorgan failure and death.
What are the symptoms of sepsis?
• Symptoms
o Fever
o Poorfeeding
o Irritable, lethargy
o History of focal infection e.g. meningitis, osteomyelitis, gastroenteritis, cellulitis o Predisposing condition e.g. SCD, immunodeficiency
What are the signs of sepsis?
o Abnormal core temperature (>38.5 or <36)
o Tachycardia(>2SDabovenormalforage)
o Tachypnoea(>2SDabovenormalforage)
o Altered mental status
o Decreased urine output (<1ml/kg/hr)
o Purpuricrash(meningococcalsepticaemia)
o Shock: cold or warm shock
▪ Cold shock: low cardiac output and high systemic vascular resistance → leads to cool extremities, prolonged CRT and poor peripheral pulses (more common)
▪ Warm shock: high cardiac output and low systemic vascular resistance→ leads to warm extremities, flash CRT and bounding pulses
o Multiorgan failure
What are the investigations of sepsis?
Septic screen
o Clinicalassessment
▪ Vital signs: blood pressure, pulse, RR, O2 sat, temperature ▪ Examination looking for sources of sepsis
o Lab tests
▪ FBC – to check for raised WCC
Bacteria more likely to drive up neutrophils
Viruses more likely to drive up lymphocytes
▪ CRP – raised in infection
▪ U&Es – acute kidney injury can occur in sepsis
▪ Lactate – raised in sepsis secondary to reduced end-organ perfusion ▪ Blood cultures
▪ Blood gas including lactate - Venous or capillary blood gas (cannot interpret oxygen pressure) + Metabolic acidosis
o Others
▪ Urine sample – dipstick and culture
• Dipstick: if nitrites and leukocytes present→send for culture
▪ Sputum sample – culture
▪ Stool sample – culture
▪ Wound swab – culture
▪ Lumbar puncture: ensure raised ICP ruled out
• Send to MC&S, virology, biochemistry (for protein and glucose) sent with a blood glucose sample
What is SEPSIS 6?
PAEDIATRIC SEPSIS 6
• Give high flow oxygen
o Via rebreathing face mask or equivalent
o Aim for SpO2 > 94%
• Obtain IV/IO access and take bloods
o Blood culture
o Blood gas inc glucose and lactate
o FBC, CRP, coagulation, U&E
o LP unless contraindicated in < 1 month old and 1-3 months if looks unwell/WCC < 5 or > 15 x 109
o Consider further investigations e.g. urine/CSF culture but do not delay treatment for this
• Give IV/IO antibiotics
o Neonates: IV benzylpenicillin + gentamicin
▪ < 3 months: also add ampicillin or amoxicillin
▪ < 1 month: cefotaxime
▪ > 1 month: ceftriaxone
o If meningococcal disease suspected: IM benzypenicillin in primary care→IV ceftriaxone in hospital
o > 1 year with suspected sepsis: IV ceftriaxone
Consider fluid resuscitation
o Aim to restore normal physiological parameters (urine output > 0.5 ml/kg/hr)
o If lactate > 2 mmol/L, give 20 ml/kg 0.9% NaCl bolus over 5-10 mins (10ml/kg if neonate)
o If lactate > 4mmol/L, call PICU
o Repeat as necessary, monitor urine output
Involve senior clinicians early
Consider inotropic support early
o If normal physiological parameters are not restored after > 40 ml/kg fluids, consider ICU admission
o Adrenaline may be given via IV/IO access
What are marker of high risk in sepsis?
Assess HIGH RISK of severe illness or death from sepsis (under 5 years):
o Behaviour:
No response to social cues
Appears ill
Does not wake, or if roused does not stay awake Weak, high-pitched and continuous cry
o Heart Rate:
Tachycardia (different at different ages)
< 60 bpm at any age
o Respiratory Rate
Approach with care
Tachypnoea (different at different ages)
Grunting
Apnoea
SpO2 < 90% on air
o Mottled or ashen appearance
o Cyanosis of the skin, lips or tongue
o Non-blanching rash
o Aged <3 months with temperature > 38 degrees
o Temperature <36degrees
How should you manage sepsis in community?
Transfer IMMEDIATELY to an acute hospital setting if there are signs of severe illness or if immunity is impaired
If in the community and meningococcal disease is suspected, give IM benzylpenicillin
When should an LP be done?
To identify source of infection
o Contraindications for LP: signs of raised ICP, foca neurological signs, shock, purpura
o Perform LP in the following children with suspected sepsis:
< 1 month
1-3 months who appear unwell
1-3 months with WCC < 5 or > 15 x 109/L
How do you manage a child with moderate-to-high-risk sepsis?
Children with MODERATE to HIGH Risk o Carry out VBG for:
▪ Blood gas (including glucose and lactate) ▪ Blood culture
▪ FBC
▪ CRP
▪ Urea and electrolytes
▪ Creatinine
o Review venous lactate within 1 hour
o Lactate > 2 mmol/L or evidence of AKI
▪ Treat as HIGH RISK o Lactate < 2 mmol/L
▪ Repeat structured assessment at least hourly
▪ Ensure review by senior clinician within 3 hours of meeting 2 or more of the moderate to high risk criteria
▪ Once the cause is identified, manage it
How do you manage a child with high risk sepsis?
Children with HIGH Risk
o Arrange immediate review by senior clinician
o Carry out VBG for:
▪ Blood gas (including glucose and lactate)
▪ Blood culture
▪ FBC
▪ CRP
▪ Urea and electrolytes
▪ Creatinine
▪ Clotting screen
o Give broad spectrum antibiotics at the MAXIMUM dose without delay o Monitor children continuously
o Monitor mental state of the child using GCS or AVPU
o Lactate > 4 mmol/L
▪ Give IV fluid bolus without delay
▪ Refer to critical care for review of central access and initiation of inotropes or
vasopressors
o Lactate 2-4 mmol/L
▪ Give IV fluid bolus without delay
o Lactate < 2 mmol/L
▪ Consider IV fluids o Antibiotics
o IV fluids
What abx do we give in sepsis?
Give IV/IO antibiotics
o Neonates <72 hrs: IV benzylpenicillin + gentamicin
▪ < 3 months: also add ampicillin or amoxicillin (to cover Listeria)
▪ < 1 month: cefotaxime
▪ > 1 month: ceftriaxone
o If meningococcal disease suspected: IM benzypenicillin in primary care→IV ceftriaxone in hospital
o > 1 year with suspected sepsis: IV ceftriaxone up to 17yrs /80mg/kg OD max 4g)
Describe the Neonatal Resuscitation Guidelines
- At birth, delayed cord clamping if possible
- Dry the baby, remove any wet towels and covers and start the clock or note the time
- Within 30 seconds: assess tone, breathing and heart rate
-
Within 60 seconds: if gasping or not breathing – open the airway and give 5 inflation breaths
- Consider SpO2 and ECG monitoring
- Re-assess: if no increase in heart rate, look for chest movement
-
If chest NOT moving:
- Check mask, head and jaw position
- Consider 2-person airway control
- Consider suction, laryngeal mask/tracheal tube
- Repeat inflation breaths and look for a response
- Consider increasing inflation pressure
- If NO increase in heart rate: look for chest movement
- When chest is moving: if heart rate is not detectable or slow (< 60/min) ventilate for 30 seconds
- Reassess heart rate: if still < 60 bpm
- Start chest compressions with ventilation breaths (3:1)
o Increase oxygen to 100%
o Consider intubation if not already done or laryngeal mask if not possible - Reassess heart rate every 30 seconds: if heart rate is not detectable or slow (< 60/min):
Describe paediatric BLS
- Approach with care
- Check responsiveness
- Shout for help
- Open airway
- Check breathing for 10s: Look, listen and feel
- Give 5 rescue breaths
- Check for signs of circulation 10s
- Femoral, brachial and radial pulses are appropriate in children
- Chest compressions: 15 chest compressions: 2 rescue breaths (15:2)
- Rate 120 compressions per minute and 30 breaths per minute
Define anaphylaxis
Definition: a severe, life-threatening generalised or systemic hypersensitivity reaction
Causes rapid onset compromise of the airway with skin/mucosal signs
Describe the pathophysiology of anaphylaxis.
In children, 85% of anaphylaxis is caused by food allergy
o Most are IgE-mediated reactions
Other causes: Insect stings, Drugs. Latex, Exercise, Inhalant allergens, Idiopathic
Most paediatric anaphylaxis occurs in children < 5 years of age, when food allergy is most prevalent
What are the clinical features of anaphylaxis?
Sudden onset and rapid progression of symptoms
Life-threatening airway and/or breathing and/or circulation problems
o Airway
▪ Throat and tongue swelling
▪ Difficult breathing and swallowing
▪ Feels throat is closing up
▪ Hoarse voice
▪ Stridor
o Breathing
▪ Shortness of breath
▪ Tachypnoea
▪ Wheeze
▪ Exhaustion
▪ Cyanosis
▪ Respiratory arrest
o Circulation
▪ Pale, clammy
▪ Tachycardia
▪ Collapse
▪ Decreased consciousness
Skin and/or mucosal changes
o Flushing
o Urticaria
o Angioedema
Gastrointestinal symptoms
o Vomiting
o Abdominalpain
o Incontinence
What is the differential diagnosis of anaphylaxis?
- Acute asthma attack
- Faint (vasovagal syncope)
- Panic attack
- Breath-holding attack
- Idiopathic urticaria/angioedema
