Our focus for this week is on recognition of Pediatric Sepsis. We have had a few cases of Group A Strep Bacteremia at SIUH in young pediatric patients over the past few weeks. I think it is important that we are all more vigilant. I will give a brief overview of how our 2 most recent cases presented. ***** This is by no means a comprehensive review of each case **** The case description will highlight the patient's presenting vitals/exam and brief course. I will not comment on details of treatment course in the ED/PICU. Please reach out to me directly with any questions.
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Patient 1:
9 yr old male, known asthmatic, presents to the ED complaining of fever and cough for about 3 days. Diagnosed with Flu B a couple days prior. Stared on Tamiflu but did not take it because could not tolerate. Decreased po on day of ED presentation.
Vitals: BP 84/49, HR 124, RR 24 (but described as having increased work of breathing and tachypneic on exam), 98.2 oral, 99% RA
Pertinent Exam:
Ill appearing
Dry mucous membranes
Tachycardic
Tachypneic, abdominal breathing, coarse lung sounds
Labs:
WBC: 1.0, Hgb 12.6, Hct 38.2, Plt 176
BMP: Na 130, K 3, Cl 89, CO2 13, BUN 17, Cr 1.5, Gluc 123, Ca 8.4, AG 28
VBG: 7.15/41/33/14
Lactate 12.6
CXR:
RVP: Flu B
Blood Culture: Positive with Group A Strep Pyogenes within 17 hours
Patient expired within 8 hours of triage.
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Patient 2:
6 yr old female, presents to the ED complaining of fever for one week and cough for about 4 days. + post tussive vomiting.
Vitals: BP 88/56, HR 158, RR 38, 98.9 oral, 94% RA
Pertinent Exam:
Tachypneic
Left sided rhonchi with decreased right sided breath sounds
Speaking in full sentences
+ Accessory muscle use
+ Tenderness to upper abdomen BL and RLQ
Labs:
WBC: 3.93, Hgb 14.4, Hct 41.9, Plt 268, Bands 56%
BMP: Na 132, K 5.3, Cl 93, CO2 21, BUN 1, Cr 0.8, Gluc 126, Ca 8.8
Lactate 4.6
CXR:
RVP: Human Metapneumovirus
Blood Culture: Positive with Group A Strep Pyogenes within 5 hours
Patient recovering after management of septic shock with multiorgan dysfunction; GAS bacteremia and right sided pneumonia w/ pleural effusion, s/p chest tube; s/p extubation; course complicated by development of R necrotizing pneumonia
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Important learning points:
THINK SEPSIS
Both of these patients were afebrile, hypotensive and tachycardic on triage
Aggressive fluid hydration with bolus fluids is encouraged, 20 cc/kg bolus dose, not drip. Up to 60 cc/kg (*exceptions excluded). See sepsis highlight and technical report attached.
Use the pediatric sepsis order set (screenshot attached)
Antibiotics should be ordered and administered expeditiously. Encourage verbal communication with nursing team to expedite the order rather than waiting for the order to be seen. Nurse may be at the bedside and not see the order right away.
https://pedemmorsels.com/pediatric-sepsis-definition-2024/
Pediatric Sepsis Definition 2024 — Pediatric EM Morsels
Let's review the revised Pediatric Sepsis Definition so we can ensure we are speaking the same language.
pedemmorsels.com
https://www.nyc.gov/site/doh/health/health-topics/streptococcal-infections-a.page
Thanks for reading,
