6 year old presenting generally unwell to ED brought in by parent
. Has been back and forward to GP and Walk in Centre over the last week.
Now tachycardic and hypovolaemic with pyrexia of 39 and is obviously septic.
The patient will continue to deteriorate, needing advanced airway management and intubation due to reducing GCS and fluid requirements.
Patient has fluid resistant shock, so will need inotropic support following initial fluid resuscitation. The Emergency department team should escalate treatment early, both within the hospital to anaesthetics/ITU and to their local PICU/paediatric retrieval service.
Up to 60% of sepsis survivors are left not only with physical challenges, but mental and emotional challenges too.
Paediatric team
Assessment and management of septic child Stabilisation Arranging transfer to PICU
Faculty Script
Oliver Smith, a 6 year old boy presents to ED referred by GP with 1/52 history of generally unwell, now drowsy, febrile, vomiting ?Gastroeneteritis. Accompanied by mum PMH NKDA, imms UTD Now tachycardic and hypovolaemic with pyrexia of 39 and is obviously septic. The patient will continue to deteriorate, needing advanced airway management and intubation due to reducing GCS and fluid requirements. Patient has fluid resistant shock, so will need inotropic support following initial fluid resuscitation. The Emergency department team should escalate treatment early, both within the hospital to anaesthetics/ITU and to their local PICU/paediatric retrieval service. When rash is found, confirm type
Actor Roles: Actor to play role of parent.
Concerned and slightly irritated that GP kept sending them away. Is quite vocal but not disruptive, is on phone texting. Rest of the family are well, no coughs and colds. Dad / mother works away only back at weekends. Older children Jenny aged 10, Milo aged 8, currently at school.
Equipment Checklist: Vascular Access Line Type Guage Type Site Other Comments Central Venous yes Arterial yes Intraosseous yes Peripheral yes - cannula Other Medical Equipment Drug Chart: √ Emergency Drug Sheet: √ Blood Results Sheet: √ IV Fluids Fluids Running Fluids Available 1 Fluids Available 2 Fluids Available 3 Other Fluids 0.9% Saline Fresh Frozen Plasma Packcells Gelofusin Dextrose Medications Infusions Dose Running Rate Available Continuous Infusion Dopamine (15mg/kg) 1ml/hr = 5mcg/kg/min Available Continuous Infusion Adrenaline (0.3mg/kg) 1ml/hr = 0.1mcg/kg/min Available Continuous Infusion Morphine (1mg/kg) 1ml/hr = 20mcg/kg/hr Available Continuous Infusion Midazolam (5mg/kg) 1ml = 100mcg/kg/hr Available Continuous Infusion Rocuronium (neat) 1ml/hr = 400mcg/kg/hr Available Continuous Infusion Noradrenaline 0.1-1mcg/kg/min Available Loading Dose 10% Dextrose 2mls/kg Bolus Drugs Dose Ceftriaxone 1.6g Paracetamol 350mg Adrenaline (1:10000) 2ml Atropine 400mcg (20mcg/kg) Fentanyl 100mcg (5mcg/kg) Rocuronium 12mg (600mcg/kg)
Expected Outcomes Participants should Facilitators should Recognise acute deterioration and consider differential diagnoses including Sepsis 6 Recognise signs of shock – hypotension, tachycardia, altered level of consciousness Administer high flow oxygen by nonbreathe mask Obtain intravenous access and if not successful progress to io insertion Request bloods including venous blood gas, FBC, U&Es, CRP, LFTS, Blood culture
Once fluid bolus given, move to prgression state; if fluid boluses not given, or inadequate fluid given, prgress to deterioration
Administer a fluid bolus 20mls/kg 0.9% saline and repeat as needed Administer IV antibiotics Consider the use of early inotropes Consider early escalation of care and retrieval
Scenario State 2 Progression - Fluid Boluses Given (Transition=inotropic support initiated )
Physiological Trends Transient increases in BP (systolic) but fluid-refractory shock is present Inotropic support is required to stabilise patient remains stable throughout intubation if appropriate oxygenation and fluid resuscitation have been given
EXPECTED OUTCOMES
Participants should Facilitators should • Identify fluid resistant shock and the need for further fluid resuscitation with 0.9% saline, 4.5% albumin or packed red blood cells • Identify the need for inotropic support and initiate dopamine centrally via the interosseous access route • Insert a second interosseous line or establish central access and continue fluid resuscitation
ASPiH Paediatric SIG This work by ASPiH Paediatric SIG is licensed under a Creative Commons Attribution-Non Commercial-No Derivs 3.0 Unported License. • Recognise the need for intubation • Prepare and plan for intubation including the consideration of the risks of hypotension on induction of anaesthesia • Avoid the use of propofol and ensure inotropic support prior to intubation to prevent hypotension and decompensation • Continue aggressive fluid resuscitation • Recognise DIC, hypoglycaemia and development of multiorgan failure • Correct hypoglycaemia with dextrose bolus • Request urgent blood products including packed red cells, fresh frozen plasma and cryoprecipitate • Recognise the need for transfer to PICU and coordinate this by contacting the retrieval team.
Scenario State 3 Progression - Post inotropic support and intubation (Transition=Discussion with the retrieval team )
Physiological Trends oxygenation post-intubation remains stable with safe management of ETT titration of inotropes should be considered along with additional fluid boluses
Expected Outcomes Participants should Facilitators should • Arrange a retrieval to PICU • Consider post stabilisation care including normocapnoea, normoglycaemia, haemodynamic support with inotropes to maintain blood pressure, thermoregulation, correct of coagulopathy with blood products. • Consider meningococcal prophylaxis for contacts including healthcare professionals and family members • Prepare for sudden deterioration and possible cardiac arrest
Scenario State 4 Deterioration - if fluid boluses not given > 40mls/kg or inotropes not commenced (Transition=)
Physiological Trends progressive tachycardia and hypotension further desaturation
Expected Outcomes Participants should Facilitators should • Recognise peri-arrest state and prepare cardiac arrest medication • Recognise the need to commence aggressive fluid resuscitation and commence inotropic support • Escalate for more help Facilitators may stop/pause the scenario if they feel the candidates are struggling/have misdiagnosed to ensure the learning outcomes are covered
. Has been back and forward to GP and Walk in Centre over the last week.
Now tachycardic and hypovolaemic with pyrexia of 39 and is obviously septic.
The patient will continue to deteriorate, needing advanced airway management and intubation due to reducing GCS and fluid requirements.
Patient has fluid resistant shock, so will need inotropic support following initial fluid resuscitation. The Emergency department team should escalate treatment early, both within the hospital to anaesthetics/ITU and to their local PICU/paediatric retrieval service.
Up to 60% of sepsis survivors are left not only with physical challenges, but mental and emotional challenges too.
Paediatric team
Assessment and management of septic child Stabilisation Arranging transfer to PICU
Faculty Script
Oliver Smith, a 6 year old boy presents to ED referred by GP with 1/52 history of generally unwell, now drowsy, febrile, vomiting ?Gastroeneteritis. Accompanied by mum PMH NKDA, imms UTD Now tachycardic and hypovolaemic with pyrexia of 39 and is obviously septic. The patient will continue to deteriorate, needing advanced airway management and intubation due to reducing GCS and fluid requirements. Patient has fluid resistant shock, so will need inotropic support following initial fluid resuscitation. The Emergency department team should escalate treatment early, both within the hospital to anaesthetics/ITU and to their local PICU/paediatric retrieval service. When rash is found, confirm type
Actor Roles: Actor to play role of parent.
Concerned and slightly irritated that GP kept sending them away. Is quite vocal but not disruptive, is on phone texting. Rest of the family are well, no coughs and colds. Dad / mother works away only back at weekends. Older children Jenny aged 10, Milo aged 8, currently at school.
Equipment Checklist: Vascular Access Line Type Guage Type Site Other Comments Central Venous yes Arterial yes Intraosseous yes Peripheral yes - cannula Other Medical Equipment Drug Chart: √ Emergency Drug Sheet: √ Blood Results Sheet: √ IV Fluids Fluids Running Fluids Available 1 Fluids Available 2 Fluids Available 3 Other Fluids 0.9% Saline Fresh Frozen Plasma Packcells Gelofusin Dextrose Medications Infusions Dose Running Rate Available Continuous Infusion Dopamine (15mg/kg) 1ml/hr = 5mcg/kg/min Available Continuous Infusion Adrenaline (0.3mg/kg) 1ml/hr = 0.1mcg/kg/min Available Continuous Infusion Morphine (1mg/kg) 1ml/hr = 20mcg/kg/hr Available Continuous Infusion Midazolam (5mg/kg) 1ml = 100mcg/kg/hr Available Continuous Infusion Rocuronium (neat) 1ml/hr = 400mcg/kg/hr Available Continuous Infusion Noradrenaline 0.1-1mcg/kg/min Available Loading Dose 10% Dextrose 2mls/kg Bolus Drugs Dose Ceftriaxone 1.6g Paracetamol 350mg Adrenaline (1:10000) 2ml Atropine 400mcg (20mcg/kg) Fentanyl 100mcg (5mcg/kg) Rocuronium 12mg (600mcg/kg)
Expected Outcomes Participants should Facilitators should Recognise acute deterioration and consider differential diagnoses including Sepsis 6 Recognise signs of shock – hypotension, tachycardia, altered level of consciousness Administer high flow oxygen by nonbreathe mask Obtain intravenous access and if not successful progress to io insertion Request bloods including venous blood gas, FBC, U&Es, CRP, LFTS, Blood culture
Once fluid bolus given, move to prgression state; if fluid boluses not given, or inadequate fluid given, prgress to deterioration
Administer a fluid bolus 20mls/kg 0.9% saline and repeat as needed Administer IV antibiotics Consider the use of early inotropes Consider early escalation of care and retrieval
Scenario State 2 Progression - Fluid Boluses Given (Transition=inotropic support initiated )
Physiological Trends Transient increases in BP (systolic) but fluid-refractory shock is present Inotropic support is required to stabilise patient remains stable throughout intubation if appropriate oxygenation and fluid resuscitation have been given
EXPECTED OUTCOMES
Participants should Facilitators should • Identify fluid resistant shock and the need for further fluid resuscitation with 0.9% saline, 4.5% albumin or packed red blood cells • Identify the need for inotropic support and initiate dopamine centrally via the interosseous access route • Insert a second interosseous line or establish central access and continue fluid resuscitation
ASPiH Paediatric SIG This work by ASPiH Paediatric SIG is licensed under a Creative Commons Attribution-Non Commercial-No Derivs 3.0 Unported License. • Recognise the need for intubation • Prepare and plan for intubation including the consideration of the risks of hypotension on induction of anaesthesia • Avoid the use of propofol and ensure inotropic support prior to intubation to prevent hypotension and decompensation • Continue aggressive fluid resuscitation • Recognise DIC, hypoglycaemia and development of multiorgan failure • Correct hypoglycaemia with dextrose bolus • Request urgent blood products including packed red cells, fresh frozen plasma and cryoprecipitate • Recognise the need for transfer to PICU and coordinate this by contacting the retrieval team.
Scenario State 3 Progression - Post inotropic support and intubation (Transition=Discussion with the retrieval team )
Physiological Trends oxygenation post-intubation remains stable with safe management of ETT titration of inotropes should be considered along with additional fluid boluses
Expected Outcomes Participants should Facilitators should • Arrange a retrieval to PICU • Consider post stabilisation care including normocapnoea, normoglycaemia, haemodynamic support with inotropes to maintain blood pressure, thermoregulation, correct of coagulopathy with blood products. • Consider meningococcal prophylaxis for contacts including healthcare professionals and family members • Prepare for sudden deterioration and possible cardiac arrest
Scenario State 4 Deterioration - if fluid boluses not given > 40mls/kg or inotropes not commenced (Transition=)
Physiological Trends progressive tachycardia and hypotension further desaturation
Expected Outcomes Participants should Facilitators should • Recognise peri-arrest state and prepare cardiac arrest medication • Recognise the need to commence aggressive fluid resuscitation and commence inotropic support • Escalate for more help Facilitators may stop/pause the scenario if they feel the candidates are struggling/have misdiagnosed to ensure the learning outcomes are covered
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