Pediatric emergency medicine trisk 68

Neurogenic Shock Assess for evidence of spinal cord injury or severe traumatic brain injury Anaphylaxis The provider should determine by history whether the patient has any known or suspected allergies to food, medications, or environmental allergens, as well as evaluate for the following physical findings: HEENT: Facial or mouth/tongue swelling Cardiac: Poor perfusion, hypotension as above Respiratory: Respiratory distress, wheezing, stridor Skin: Urticarial rash Septic Shock The provider should determine by history whether the patient has any underlying conditions which may predispose them to septic shock including neonatal age, innate or acquired immunodeficiency or immunosuppression (including malignancy, sickle cell disease and other causes of asplenia, bone marrow or solid organ transplant), or the presence of an indwelling central venous catheter or other invasive hardware In addition, they should evaluate carefully for evidence of end-organ dysfunction on physical examination as described by organ system below (and summarized in Table 10.2 ): Cardiac: Poor perfusion (diminished or bounding pulses, flash capillary refill or delayed [>3 seconds] capillary refill, abnormally cool or warm extremities, mottling) Respiratory: Tachypnea (from lung infection and/or metabolic acidosis), signs of respiratory distress or failure Hematologic: Rashes suspicious for disseminated intravascular coagulation such as petechiae or purpura; or a toxin-mediated process manifested as erythroderma Neurologic: Altered mental status Renal: Decreased urine output POCUS findings: Early findings may overlap with hypovolemic shock with evidence of fluid responsiveness (measured by respiratory variation in IVC diameter in the longitudinal view) and normal or hyperdynamic ventricular function Myocardial dysfunction may evolve with evidence of ventricular dysfunction Repeated assessment can be helpful Diagnostic Testing in Septic Shock Laboratory testing in suspected septic shock is focused on determining evidence of end-organ dysfunction and recommended testing is listed by organ system below (and is summarized in Table 10.3 ): Cardiac: Lactate, base deficit, central venous oxygen saturation (ScvO2 ) (if central line present) measured by co-oximetry Respiratory: Blood gas analysis Hematologic: Complete blood count to assess for leukopenia, anemia, thrombocytopenia, coagulation studies to assess for coagulopathy/disseminated intravascular coagulation Renal: Serum creatinine Hepatic: Transaminases, bilirubin Microbiologic: Blood culture, other bacterial testing based on suspected source (e.g., urinalysis, urine culture, chest x-ray, lumbar puncture, etc.) TABLE 10.2 ORGAN DYSFUNCTION DEFINITIONS (ADAPTED FROM INTERNATIONAL PEDIATRIC SEPSIS CONSENSUS CONFERENCE STATEMENT) Organ system Definition of dysfunction Cardiovascular Despite administration of isotonic IV fluid bolus of at least 40 mL/kg in hr, presence of ANY of the following: • Hypotension 5 mEq/L) • Increased arterial lactate >2ì upper limit of normal ã Oliguria: Urine output 5 sec • Core to peripheral temperature gap >3°C Respiratory Presence of ANY of the following: • PaO2 /FiO2 65 Torr or 20 mm Hg over baseline PaCO2 • Proven need for >50% FiO2 to maintain saturation >92% • Need for nonelective invasive or noninvasive mechanical ventilation Neurologic Presence of EITHER: • Glasgow coma score ≤11 • Acute change in mental status with a decrease in Glasgow coma score ≥3 points from abnormal baseline Hematologic Presence of EITHER: • Platelet count 2 Renal Presence of EITHER: • Serum creatinine ≥2× upper limit of normal for age • Twofold increase in baseline creatinine Hepatic Presence of EITHER: • Total bilirubin ≥4 mg/dL (not applicable for newborn) ... x-ray, lumbar puncture, etc.) TABLE 10.2 ORGAN DYSFUNCTION DEFINITIONS (ADAPTED FROM INTERNATIONAL PEDIATRIC SEPSIS CONSENSUS CONFERENCE STATEMENT) Organ system Definition of dysfunction Cardiovascular