25. Septic shock in the ED
Dr. Mike Ross: Hello, I’m Dr. Ross. What brings you in?
Mother: Hi Dr. Ross. My son Luke started with fever this morning. He hardly ate any breakfast and he’s vomited three hours ago. He has been very sleepy. My child is now two years old and has always been healthy, he’s just not himself.
Dr. Mike Ross: Alright, let me take a look.
Ill appearance. Capillary refill time: 4 seconds. Normal symmetrical peripheral pulses. No rashes or petechiae. Polypnea, without other signs of respiratory distress. Neurological: arousable to tactile and loud verbal stimuli, occasionally crying without facial asymmetries and moving all extremities. PERRL. Closed anterior fontanelle. No neck stiffness, absent meningeal signs. Cardiac auscultation: tachycardia, systolic heart murmur. Pulmonary auscultation: general good bilateral ventilation, no pathological breath sounds. HEENT: hyperemic oropharynx. Normal tympanic membranes. Normal abdomen, no organomegalies.
Dr. Mike Ross (to the nurse): Jeff, let’s place him on the monitor, we need to check his vitals.
Dr. Mike Ross (to the mother): Ms., Luke appears to have a serious infection. I’m going to call my colleague and we will be right back.
Dr. Mike Ross: Hi Dr. Manning, a 2-year-old child has just been brought in with high fever. He is ill – appearing, lethargic, tachycardic, polypneic and his capillary refill is 4 seconds. I think he might be septic. Could you come and take a look at him?
Dr. Manning: Of course, let’s go!
Dr. Manning takes a look at the patient.
Jeff: Dr. Manning, his heart rate is 176 bpm, his blood pressure is 85/45 mmHg and he is breathing at 45 bpm. His oxygen saturation is 95%. I’ve asked his mother and his weight is 15 kg.
Dr. Manning: Thanks Jeff. It seems we have a septic shock here. Mike, start him on a nonrebreathing mask. Jeff, we need to get an IV access as quickly as possible. Once you have it, administer a fluid bolus with 300 ml of normal saline at maximum pump speed.
Dr. Manning: Ms. Would you mind waiting outside while we take care of Luke? We’ll update you as soon as possible.
Dr. Mike Ross: Could we get another nurse here, please?
Dr. Manning:Hi Nathalie, this is a 2-year old with a septic shock, we need another IV access for tests and antibiotics.
Dr. Mike Ross: Dr. Manning, I’ll order a VBG, CBC, CMP and a blood culture, and I’ll calculate the antibiotics. He’s two years old, so I’ll start him on cefotaxime and vancomycin, OK?
Dr. Manning: Great, thank you Mike. After that, please update the mother, and ask her for any relevant past medical history and allergies.
Jeff: Dr. Manning, his BP is dropping to 78/40 and we’re having trouble with the IV access.
Dr. Manning: OK, I’m placing an IO access. Get Mike to call the PICU.
Dr. Mike Ross (to the PICU team): Hi, I’m Dr. Ross, I’m calling from the ED because we have a patient with septic shock. Luke Ferguson is a 2-year-old boy with no past medical history. He started with fever this morning and he now has signs of abnormal perfusion. Right now, he is lethargic, polypneic with a nonrebreathing mask, his heart rate is 180 bpm and his BP is 80/42 after the first fluid bolus. He shows no signs of fluid overload. We have an IO access, and are now on the second fluid bolus. We have already sent a VBG, CBC, CMP and blood culture to the lab and are about to start him on broad – spectrum antibiotics. I think he needs to be transferred to the PICU for a definitive IV access, monitoring and treatment with vasopressors if needed.
PICU team: Alright, bring him in.
Septic shock: shock séptico.
Ill appearance: mal aspecto.
Normal symmetrical peripheral pulses: pulsos periféricos normales y simétricos.
Arousable to tactile and loud verbal stimuli: Despierta con estímulos táctiles y a la voz fuerte.
PERRL (pupils are equal, round and react to light): isocoria, pupilas redondas y normorreactivas a la luz.
Neck stiffness: rigidez de nuca.
Absent meningeal signs: no signos meníngeos.
Place on the monitor: conectar al monitor.
Check vitals: tomar constantes.
Nonrebreathing mask: mascarilla con reservorio.
IV (intravenous) access: acceso intravenoso.
Fluid bolus: bolo de volumen.
Maximum pump speed: máxima velocidad de la bomba.
VBG (venous blood gas): gasometría venosa.
CBC (complete blood count): hemograma.
CMP (complete metabolic panel): bioquímica completa.
Blood culture: hemocultivo.
BP (blood pressure) is dropping: la presión arterial está cayendo.
IO (intraoseus) access: acceso intraóseo.
PICU (Pediatric Intensive Care Unit): UCIP (Unidad de Cuidados Intensivos Pediátricos).
Abnormal perfusión: perfusión anormal.
Fluid overload: sobrecarga de volumen.
Broad – spectrum antibiotics: antibióticos de amplio espectro.
Vasopressors: drogas vasoactivas.