Pediatric emergency medicine trisk 1463 1463

gravely ill with apnea, bradycardia, hypothermia, bradypnea, or seizures However, a careful physical examination suggests abuse rather than sepsis Bruises may be present on the body, though more often, no external evidence of trauma is present Respiratory distress without stridor or lower airway sounds may be due to central nervous system dysfunction The head circumference is often at or above the 90th percentile, and the fontanel may be full or bulging Retinal hemorrhages are often found and strongly suggest intracranial hemorrhage from trauma Some neurologic signs may be confused with meningitis, such as nuchal rigidity, irritability, coma, seizures, or posturing Although the CBC often shows a leukocytosis and thus is confusing, the spinal fluid from a shaken baby is usually bloody and fails to clear as the fluid is collected A noncontrast CT scan or magnetic resonance imaging (MRI) usually demonstrates a small posterior, interhemispheric subdural hematoma Such shaken babies have a high incidence of serious morbidity and mortality EVALUATION AND DECISION Presume that any infant who is critically ill in the first few weeks of life may be septic It is imperative to stabilize the baby rapidly ( Fig 73.1 ) because this lifethreatening situation may respond to early treatment Restore airway, breathing, and circulation and obtain vascular access Intraosseous access should be used if IV access cannot be obtained rapidly, and the patient may require vigorous fluid resuscitation Perform rapid bedside testing for glucose Unless another diagnosis is immediately obvious, it is best to give intravenous antibiotics while pursuing alternative diagnoses If time permits, send cultures to the laboratory before giving antibiotics Administer prostaglandins if cardiogenic shock with PDA closure is suspected