Joint EM-Pediatric Conference Pediatric Sepsis
Pediatric sepsis is culture negative in 25-60% of cases.
About half of children with sepsis will have a low cardiac index and high SVR (cold shock) where 90% of adults will have high cardiac output and low SVR (warm shock)
*Pediatric Sepsis Definitions
Cornerstones of Sepsis Therapy in Children
Early recognition is the key to treating sepsis effectively.
A key resuscitation goal is 60ml/kg of normal saline infused in the first hour.
Vascular access in the septic child should escalate to IO after 2 attempts at IV.
IO placement is not more painful than IV placement but IO infusions are painful. So give lidocaine 0.5 mg/kg, not to exceed 40 mg thru the IO line. (Lovell reference)
You need to use a pressure bag, rapid infuser, or push-pull method to give 60ml/kg within one hour.
There was a discussion of which patients should get 60ml/kg in the first hour. The strong consensus was that all pediatric sepsis patients should receive 60ml/kg of NS.
You should be cautious giving 60ml/kg to kids with cardiac disease, history of abnormal kidney function, and neonates.
The panel felt that, in general, septic kids need more rather than less fluid.
The panel felt that it would be reasonable to re-assess the patient after every 20ml/kg.
Neonates are a high-risk group for large volume fluids and should be bloused in no more than 10ml/kg aliquots at a time. You should carefully re-assess the neonate after any bolus to determine if more fluids are required.
Early antibiotics are another cornerstone of sepsis management. A 3 hours delay increases the likelihood of need for PICU admission. Ampicillin & Cefotaxime or Vancomycin &Ceftriaxone are the basic empiric antibiotic combos. But there are many variations based on age, allergies, and source of infection.
If you need a pressor for sepsis in a pediatric patient use peripheral epinephrine. It has lower mortality compared to dopamine.
Children who are on chronic steroids (asthma, cancer) are at risk for adrenal suppression. Give hydrocortisone (2mg/kg) Q 6 hours in septic kids who are at risk.
All kids in septic shock should receive hi-flow nasal cannula O2.
To avoid a hemodynamic crash during or after intubation, give a fluid bolus prior to intubation. Consider an epinepherine drip prior to intubation.
The Panel suggested avoidingetommidate for RSI in septic children. I assume that is based on concern for adrenal suppression and maybe a risk of hypotension.
Lactate levels are unreliable in kids for identifying sepsis.
Basically in the first hour after you suspect sepsis:
Give 60ml/kg of NS, Start IV antibiotics, Start high flow O2 via nasal cannula. If you need a pressor give IV epinephrine.
Kerwin/Denk Oral Boards
Case 1. 25yo female with severe dyspnea. Patient has a history of asthma and is severely wheezing. Despite therapy with nebulizers, magnesium, and subcutaneous epinepherine, the patient was still in severe distress and the ABG shows respiratory acidosis. Patient was then intubated using a sedated look with ketamine for sedation and topical lidocaine.
*Use peak flows to determine severity of asthma.
Give 10-15mg of albuterol nebs every hour for severe asthma. Give steroids and IV magnesium. You can also try high flow nasal cannula, heliox, subcutaneous terbutaline or IM epipepherine. Sub-dissociative dosing (0.1mg/kg)etamine may be helpful in the anxious/agitatedpatient to help them tolerate bipap and nebs to stave off intubation. Bipap should be tried but the data in asthma for bipap is limited.
Case 2. 68yo male presents in Cardiac arrest. Patient had V-tach as his initial rhythm. In the ED, patient was in V-fib . ACLS protocol was initiated. ROSC was obtained. EKG post-arrest showed STEMI. Asa and heparin were given and patient was taken to the cath lab. Therapeutic hypothermia was initiated as cath lab was being activated.
Chris advised that if repeated shocks for V-fib are not working, try double shocking with two defibrillators at the same time. There are a few small case series showing some efficacy to this method.
*Double defibrillation method for persistent V-fib
*2015 ACLS Guidelines recommend Amiodarone and epinephrine for treating ventricular fibrillation that is resistant to first shock.
Therapuetic hypothermia is indicated after V-fib arrest either with or without STEMI.
*Some criteria that make therapeutic hypothermia less likely to have a postive outcome. My brief review of the literature would add: unwitnessed arrests, asystole/PEA arrests, significant delays to starting CPR and ACLS care, intracranial hemorrhage, subarachnoid hemorrhage, pre-arrest inability to perform ADL's, and arrest due to sepsis.
Case 3. 56 yo male with altered mental status and vomiting. Patient had a headache earlier in the day. Patient has a history of HTN and Afib. Patient is on xarelto and aspirin. Head CT shows ICH. Treatment is with FEIBA or PCC’s.
The data shows that lowering the BP to less than 140 systolic has worse outcomes. Goal should be a BP just above 140 mm/hg systolic.
Yasser Said Observation Medicine
Kelly comment: The phrase I use for documenting chest pain patients in the OBS unit is: Patient placed on OBS service for further cardiac risk stratification.
Elderly and frail patients should be considered for inpatient management over OBS management.
AARP has advised people to refuse OBS stays because OBS stays are more expensive. This is not always true. It really varies on a case-to-case basis.
Average OBS stay is 20-22 hours
OBS service has a policy of Dilaudid restriction. Please inform patients that this medication will be restricted in OBS.
Physicians can be criminally prosecuted for prescribing opioids to a patient who has an overdose or bad outcome.
Pharmacy Lecture Status Epilepticus Management
1st line IV lorazepam (2-4mg) or IM midazolam (5-10mg) or IV diazepam
Rectal diazepam (0.2mg/kg) is another option for patients without IV access
2nd line IV phosphenytoin or IV Valproic acid or IV levetiracetam or IV Phenobarbitol. Loading dose for all these agents is 20mg/kg.
Refractory Status is due to less responsive GABA receptors and increased NMDA receptors.
3rd line Propofol 80micrograms/kg/hr or IV midazolam drip.
4th line Ketamine1-5mg/kg followed by drip 0.45-10mg/hr.
Subclinical status can be indicated by persistent tachycardia.