Pediatric emergency medicine trisk 1467 1467

(abdominal
mass)

cystourethrogram
Blood urea nitrogen,
creatinine

CT and MRI refer to intracranial imaging in this table.
ECG, electrocardiogram; CT, computed tomography; MRI, magnetic resonance imaging; PCR, polymerase
chain reaction.

Obtain a complete history including any previous medical problems such as
known heart disease or failure to thrive. Determine the time of onset of
symptoms, exposure to infection, medications given at home, and specific
symptoms noted by the parents. Next, perform a careful physical examination
because specific findings may lead to a diagnosis other than sepsis ( Table 73.3 ).
Follow with laboratory evaluation as indicated by findings on history and
physical examination. Promptly obtain a rapid test for blood sugar as
abnormalities may be life-threatening. For all sick infants, obtain a blood culture
and a urine culture, by either urethral catheter or suprapubic bladder tap. Perform
a lumbar puncture unless physical findings point strongly to a diagnosis other
than sepsis or the infant is too critically ill to tolerate the procedure (e.g.,
respiratory distress). Bruising or bleeding with intravenous access attempts
suggests the possibility of DIC and is a contraindication for lumbar puncture. If
available, send a CSF panel to rapidly detect pathogens associated with
meningitis and encephalitis by PCR. A chest radiograph is also essential to look
for pulmonary infection and to evaluate the heart size. Obtain a CBC as
leukocytosis will add support to a suspicion of sepsis and may also be found in
various other disorders including viral infections, myocarditis, pericarditis,
intracranial bleeds, NEC, appendicitis, intussusception, and methemoglobinemia.
For all sick infants, send studies to evaluate serum sodium, potassium, chloride,

glucose, and bicarbonate level, as metabolic problems (disturbances in acid–base
balance, electrolytes, blood sugar) can result from sepsis or be the primary
problem that mimics sepsis. If hyponatremia is found, consider water
intoxication, aspirin toxicity, cystic fibrosis, and CAH. If there is also a marked
hyperkalemia, CAH is most likely. If there is hypochloremic alkalosis or alkalosis
alone, then consider pyloric stenosis, aspirin toxicity, or gastroenteritis.
Hypoglycemia may be secondary to poor glucose reserves in an ill infant or
related to drug (aspirin) toxicity, inborn errors of metabolism, CAH, or
methemoglobinemia. The presence of acidosis could be due to poor perfusion
caused by shock, as well as primary problems such as dehydration, drug toxicity,
methemoglobinemia, appendicitis, CAH, and inborn errors of metabolism. In