Pediatric emergency medicine trisk 0282 0282

tailored to the local antibiogram, suspected source of infection, and patient age (
Table 10.5 ). Seasonal patterns in virus activity should also be considered and
antiviral agents for influenza should be included in the initial antimicrobial
regimen during influenza season. Intramuscular administration of antibiotics
should be considered if access to the IV or intraosseous route is delayed.
In addition to the common community-acquired pathogens, infants under 2 to 3
months are at risk for infections with group B Streptococcus, coagulase-negative
Staphylococcus, Listeria monocytogenes, gram-negative organisms such as
Escherichia coli and Haemophilus influenzae, and herpes simplex virus. They are
also at increased risk for central nervous system infections, so initial antibiotic
choice should include coverage for these organisms and adequate doses to
penetrate the central nervous system.
For anaphylactic shock, epinephrine is the definitive treatment, and
epinephrine infusion may be needed for those with shock refractory to
intermittent dosing of epinephrine. Removal of the inciting allergen and
administration of antihistamines and corticosteroids should occur concurrently.

PROTOCOL-BASED CARE FOR SEPTIC SHOCK
Although the goal of rapid shock recognition and reversal applies to all types of
shock, there has been a specific focus on improving recognition and care of
pediatric patients with septic shock. The following discussion is thus focused on
sepsis, although the general principles likely apply to other shock types as well.

Timely Antimicrobial and Fluid Resuscitation Therapy
Timely antimicrobial therapy and fluid resuscitation are essential in the treatment
of severe sepsis and septic shock. In critically ill adults with sepsis, evidence
suggests that delays in appropriate antimicrobial therapy increase mortality. Data
also demonstrate that delays in antibiotic administration are associated with
increased mortality and prolonged organ dysfunction in pediatric sepsis. In
addition, these studies demonstrate the importance of appropriate antibiotic
selection in improving sepsis outcomes. Institutional antibiograms can help to

facilitate antibiotic selection in sepsis, and are typically based on host factors,
suspected source, and local microbial susceptibility patterns.
In addition to antimicrobial therapy, rapid shock reversal via fluid resuscitation
and appropriate vasoactive medications is essential to improve outcomes in septic
shock. Multiple studies have demonstrated improved survival after septic shock
in adults with early goal-directed therapy aimed at reversing shock, though the
optimal method by which to titrate resuscitation is not clear. The ProCESS,
PROMISE, and ARISE trials found no difference in outcomes whether shock