Episode 50 Recognition and Management of Pediatric Sepsis and Septic Shock

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.....



Written Summary & Blog post Prepared by Michael Kilian & Niran Argintaru, edited by Anton Helman, August 2014

Cite this podcast as: Helman, A, Reid, S, Neto, G. Recognition and Management of Pediatric Sepsis and Septic Shock. Emergency Medicine Cases. August, 2014. https://emergencymedicinecases.com/episode-50-recognition-management-pediatric-sepsis-septic-shock/. Accessed [date].

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:

* Of the children <1yr, most will be





* 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

Normal Pediatric Vital Signs







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 ...