This case is written by Dr. Rob Woods. He works in both the adult and pediatric emergency departments in Saskatoon and has been working in New Zealand for the past year. He is the founder and director of the FRCP EM residency program in Saskatchewan.
Why it Matters
This case highlights important manifestations of sepsis in a neonate. In particular, it reinforces that:
- Apneas, hypoglycemia, and hypothermia are commonly seen as a result of systemic illness in neonates
- Prolonged or persistent apneas with associated desaturations require management with either high-flow oxygen or intubation
- Fluid resuscitation and broad-spectrum antibiotics are important early considerations when managing toxic neonates
To be stated by the Paramedic with the Resus Nurse at bedside: “We picked up this term 3-day old male infant at their GPs office. Mom reports poor feeding for the past 12 hours, and two episodes of vomiting. They took him to the GPs office this morning and they found the temperature to be quite low at 33.1°C. They called us concerned about sepsis. We were only 5 minutes away so we have not obtained IV access. We did obtain a glucose level of 2.7. The child is lethargic and has very poor perfusion – peripheral cap refill is 7 seconds. We don’t have a cuff to get an accurate BP but the HR is 190.”
A 3-day-old term male infant is brought to the ED by EMS after being seen at their Family Physician’s office with a low temperature (33.1oC). The child has been feeding poorly for about 12 hours, and has vomited twice. He is lethargic on examination and poorly perfused with intermittent apneas lasting ~ 20 seconds. He requires immediate fluid resuscitation and broad-spectrum antibiotics. His perfusion will improve after IVF boluses, however the apneas will persist and necessitate intubation.
Initial CXR for the case found here:
(CXR source: http://emedicine.medscape.com/article/414608-overview)
Post-intubation CXR for the case found here:
(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)
This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.
Why it Matters
Children with true septic shock are, thankfully, a rare presentation in the ED. However, recognition of early shock is an essential skill. This case highlights several important features of managing the critically ill child, including:
- The need for early vascular access (whether that be intravenous or intraosseous, it must be obtained expediently)
- The importance of monitoring for and treating resultant hypoglycemia
- The need for early antibiotics
A 4-year-old girl presents to your pediatric ED. Her mother states she is “not herself” and seems “lethargic.” She’s had a fever and a cough for the last three days. Today she just seems different. She was brought straight into a resus room and the charge nurse came to find you to tell you the child looks unwell.
A 4 year-old girl is brought to the ED because she is “not herself.” She has had 3 days of fever and cough and is previously healthy. She looks toxic on arrival with delayed capillary refill, a glazed stare, tachypnea and tachycardia. The team will be unable to obtain IV access and will need to insert an IO. Once they have access, they will need to resuscitate by pushing fluids. If they do not, the patient’s BP will drop. If a cap sugar is not checked, the patient will seize. The patient will remain listless after fluid resuscitation and will require intubation.
ECG for the case found here:
(ECG source: http://lifeinthefastlane.com/ecg-library/sinus-tachycardia/)
CXR for the case found here:
(CXR source: http://radiopaedia.org/articles/round-pneumonia-1)
This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY5 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.
Why it Matters
Although recent literature has challenged the use of protocolized care in the management of sepsis, this case highlights the key points that are crucial in early sepsis care, namely:
- The recognition of sepsis and identifying a likely source of infection
- The initiation of broad-spectrum antibiotics in the emergency department
- Hemodynamic resuscitation with intravenous fluids and vasopressor therapy
You are working a day shift at a community hospital emergency department. You are handed a chart of a patient presenting with abdominal pain. You recognize the following vital signs: Heart rate 120, blood pressure 85/55, respiratory rate 20, and O2 Saturation 95%.
A 60-year-old male presents with a four-day history of abdominal pain secondary to cholangitis. The patient presents in septic shock requiring intravenous fluid resuscitation, empiric broad-spectrum antibiotics and vasopressor support and suffers a PEA arrest prior to disposition to advanced imaging or definitive management.
Download the case here: Cholangitis
ECG for case found here:
(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)
CXR for case found here:
Ultrasound for case found here: