Pediatric emergency medicine trisk 68

Neurogenic Shock . Assess for evidence of spinal cord injury or severe
traumatic brain injury.
Anaphylaxis . The provider should determine by history whether the patient
has any known or suspected allergies to food, medications, or environmental
allergens, as well as evaluate for the following physical findings:
HEENT: Facial or mouth/tongue swelling
Cardiac: Poor perfusion, hypotension as above
Respiratory: Respiratory distress, wheezing, stridor
Skin: Urticarial rash
Septic Shock . The provider should determine by history whether the patient
has any underlying conditions which may predispose them to septic shock
including neonatal age, innate or acquired immunodeficiency or
immunosuppression (including malignancy, sickle cell disease and other causes of
asplenia, bone marrow or solid organ transplant), or the presence of an indwelling
central venous catheter or other invasive hardware. In addition, they should
evaluate carefully for evidence of end-organ dysfunction on physical examination
as described by organ system below (and summarized in Table 10.2 ):
Cardiac: Poor perfusion (diminished or bounding pulses, flash capillary refill or
delayed [>3 seconds] capillary refill, abnormally cool or warm extremities,
mottling)
Respiratory: Tachypnea (from lung infection and/or metabolic acidosis), signs
of respiratory distress or failure
Hematologic: Rashes suspicious for disseminated intravascular coagulation
such as petechiae or purpura; or a toxin-mediated process manifested as
erythroderma
Neurologic: Altered mental status
Renal: Decreased urine output
POCUS findings: Early findings may overlap with hypovolemic shock with
evidence of fluid responsiveness (measured by respiratory variation in IVC
diameter in the longitudinal view) and normal or hyperdynamic ventricular
function. Myocardial dysfunction may evolve with evidence of ventricular

dysfunction. Repeated assessment can be helpful.
Diagnostic Testing in Septic Shock
Laboratory testing in suspected septic shock is focused on determining evidence
of end-organ dysfunction and recommended testing is listed by organ system


below (and is summarized in Table 10.3 ):
Cardiac: Lactate, base deficit, central venous oxygen saturation (ScvO2 ) (if
central line present) measured by co-oximetry
Respiratory: Blood gas analysis
Hematologic: Complete blood count to assess for leukopenia, anemia,
thrombocytopenia, coagulation studies to assess for coagulopathy/disseminated
intravascular coagulation
Renal: Serum creatinine
Hepatic: Transaminases, bilirubin
Microbiologic: Blood culture, other bacterial testing based on suspected source
(e.g., urinalysis, urine culture, chest x-ray, lumbar puncture, etc.)


TABLE 10.2
ORGAN DYSFUNCTION DEFINITIONS (ADAPTED FROM
INTERNATIONAL PEDIATRIC SEPSIS CONSENSUS CONFERENCE
STATEMENT)


Organ system

Definition of dysfunction

Cardiovascular Despite administration of isotonic IV fluid bolus of at least 40

mL/kg in 1 hr, presence of ANY of the following:
• Hypotension <5th percentile for age
• Need for vasoactive medication to maintain normal blood
pressure
• Two of the following:
• Unexplained metabolic acidosis (base deficit >5 mEq/L)
• Increased arterial lactate >2ì upper limit of normal
ã Oliguria: Urine output <0.5 mg/kg/hr
• Prolonged capillary refill >5 sec
• Core to peripheral temperature gap >3°C
Respiratory
Presence of ANY of the following:
• PaO2 /FiO2 <300 in absence of cyanotic heart disease or preexisting lung disease
• PaCO2 >65 Torr or 20 mm Hg over baseline PaCO2
• Proven need for >50% FiO2 to maintain saturation >92%
• Need for nonelective invasive or noninvasive mechanical
ventilation
Neurologic
Presence of EITHER:
• Glasgow coma score ≤11
• Acute change in mental status with a decrease in Glasgow
coma score ≥3 points from abnormal baseline
Hematologic
Presence of EITHER:
• Platelet count <80,000/mm3
• Decline of 50% platelet count from highest value recorded
over past 3 days (for chronic hematology/oncology
patients)
• International normalized ratio >2
Renal

Presence of EITHER:
ã Serum creatinine 2ì upper limit of normal for age
• Twofold increase in baseline creatinine
Hepatic
Presence of EITHER:
• Total bilirubin ≥4 mg/dL (not applicable for newborn)