IN THE emergency department (ED) environment, abdominal pain and vomiting are some of the most common pediatric complaints. These presentations are the principal complaint of 6.8% of ED visits across all age groups (Tintinalli, Stapczynski, Ma, Cline, & Meckler, 2011a). The differential diagnoses can be expansive with a wide variation of severity of illness and injury.
The case study presented herein illustrates the importance of initial assessment, meticulous investigation, rapid empiric treatment, and using evidence-based guidelines for children presenting with sepsis.
A CRITICALLY ILL CHILD: CASE IN REVIEW
History of Present Illness: Patient Presentation
T.B. was a 21-month-old male child who presented to a community ED through triage with his mother. The mother stated that she was concerned that her son "had the flu." The mother stated that he had a fever that she noticed that morning and had not been eating well since the previous night. She indicated that her son vomited green fluid once that morning and was complaining of abdominal pain. The mother explained that she had responsibility for T.B. from Monday to Friday, and the grandparents watched him on the weekends. It was Saturday morning. The mother reported that she and T.B. had been "staying at the casino for the last four days, he was running around and playing the whole time until last night." The mother appeared detached from T.B. and said that she "only came because my father told me to."
The initial visual assessment, also referred to as the pediatric assessment triangle (PAT), performed by the triage nurse, quickly determined that this child was unstable. See Table 1.
Past Medical History
Once in the treatment room, the mother denied any past medical history or surgical procedures. There were no known complications at birth, the delivery was a normal spontaneous vaginal delivery, and birth occurred at 39 weeks of gestation. The patient was up to date on his required childhood immunizations but had not received a flu vaccination within the last year. T.B. had no siblings. His mother denied alcohol or drug use during pregnancy or currently. She was a single mother, unemployed, uninsured, and a poor historian. T.B.'s mother denied any known allergies for him and stated that he did not take any medications regularly. She had not given him anything for the present illness because "it just came on this morning."
Physical Examination
Initial vital signs were as follows: Temperature: 39.2 [degrees]C (102.6 [degrees]F); rectal heart rate (HR): 190; apical respiratory rate (RR): 35; pulse oximetry: 98% at room air, which was within normal limits; blood pressure: 101/54 mmHg; weight: 15.4 kg/33 lb 15 oz (greater than 90th percentile); and capillary refill less than 2 s.
The immediate general impression of the patient was that he appeared poorly cared for as evidenced by soiled clothes and lack of cleanliness. He was well developed and well nourished but, more importantly, appeared toxic as evidenced by his poor response to interaction and listlessness. Upon further examination, the patient's skin was dry, dusky, and appeared ashen. His face was symmetrical, the anterior fontanel was soft and sunken, and the posterior fontanel was closed. The head was normocephalic without deformity, the neck was supple, the trachea was midline, and no cervical lymphadenopathy or thyromegaly was palpated. He was unable to follow objects with his gaze, and his pupils were dilated with sluggish response to light. He did not produce tears, even when agitated. T.B.'s ear canals were patent and his tympanic membranes were intact and clear with no pre- or postauricular lymphadenopathy. The nares were crusted and inflamed, the nasal airway was patent, and his oral mucosa was dry with cracked lips. The neck was supple with a full range of motion and no meningismus or nuchal rigidity. Lung sounds were clear and equal bilaterally, and no respiratory distress was noted. The patient's pulse was rapid, regular, bounding, and symmetrical when centrally palpated in the femoral region. The heart tones were normal with no murmurs or gallops. There was no cyanosis, and his capillary refill time was less than 2 s. The abdomen was distended and rigid with hypoactive bowel sounds. There was no bruising or signs of obvious trauma, and the mother could not recall the last bowel movement. Upon palpation, there was involuntary guarding, with no masses or peristaltic movements noted. Upon inspection of his back, there was no spinal or costovertebral tenderness. His diaper was dry and did not appear to have been changed for some time. The external genitalia were normal, with no rash or hernia noted. The patient moved all four extremities against gravity but not resistance and had a flaccid muscle tone with weak bilateral grasps. The neurological assessment was limited to observation of a weak cry and minimal response to pain when peripheral intravenous (PIV) access was obtained. Initial Glasgow Coma Scale score for this patient was 9, with eyes opening spontaneously, no speech, and withdrawal from pain (Teasdale & Jennett, 1974). See Table 2.
Initial Management
The triage nurse administered ibuprofen 154 mg orally (10 mg/kg) for the fever per the hospital policy. When obtaining vital signs, the triage nurse noticed that the child had not made any verbal sounds and asked the mother whether the child speaks. The mother stated, "You know, it is the weirdest thing ... usually he doesn't stop talking but for the last two days he hasn't said a word." The triage nurse recognized this as a possible indication of lethargy, and the patient was promptly brought to an ED treatment room for immediate attention by the health care team.
Upon completing the triage information, T.B. was given an Emergency Severity Index score of 2, as the triage nurse recognized that this was a high-risk patient with an altered mental status manifesting as lethargy and aphasia that required immediate interventions (Gilboy, Tanabe, Travers, & Rosenau, 2012). The physical examination was completed by the primary ED nurse while T.B. was being undressed in the treatment room. A pediatric crash cart was also brought to the treatment room upon recognition of the severity of this child's illness. The pediatric crash cart equipment was organized according to weight and correlated with recommendations of a length-based weight resuscitation tape (Broselow & Hinkle, 1993).
A pulse oximeter, a heart monitor, and a blood pressure cuff were placed upon disrobing the patient. A 22-gauge PIV catheter was placed in the left antecubital area, blood was drawn for laboratory analysis, and the site was secured with an arm board. Urinary catheterization was carried out with 6 ml of urine initially collected. A nasal swab for rapid influenza/respiratory syncytial virus testing was also collected. The bedside glucose result was 109 mmol/L. A complete blood cell count, complete metabolic panel, blood type and screen, blood cultures, and a urine toxicology panel to rule out possible drug ingestion as the cause of lethargy and altered mental status were ordered STAT. Fluid resuscitation with 0.9% normal saline was initiated at 20-ml/kg rapid infusion (300-ml intravenous bolus). Antibiotic treatment was begun immediately following collection of blood culture specimens. As bacterial meningitis, antibiotic-resistant infection strains, and septicemia were not yet ruled out, ceftriaxone 1.5 gm intravenously (over 30 min) and vancomycin 150 mg intravenously (more than 90 min) were ordered. These antibiotics were used as broad-spectrum, empirical coverage for gram-positive (vancomycin) and gram-negative (ceftriaxone) organisms. Acetaminophen 230 mg orally (15 mg/kg) was also administered for further fever reduction.
Laboratory Results
The results of the laboratory tests began to arrive while empirical treatment was carried out. Results of the urine toxicology panel were negative, and no salicylate or acetaminophen levels were detected. The abnormal metabolic panel findings included carbon dioxide of 12 mmol/L (low), anion gap of 31 mmol/L (high), and creatinine of 1.30 mg/dl (high). The complete blood cell count reported a white blood cell count of 4.5 x 103/mcl (low), with zero neutrophils both segmented and absolute. His hemoglobin was 12.4 g/dl, hematocrit was 38.7%, and an elevated lymphocyte count of 89%. The rapid influenza screen was positive for influenza A.
Imaging
An abdominal computed tomographic (CT) scan was ordered to evaluate the rigid abdomen with involuntary guarding, a head CT scan was ordered to evaluate the altered mental status and flaccid tone, and a chest radiograph was ordered to rule out pneumonia or other cardiopulmonary causative factors. The radiologist read the chest radiograph and the head CT scan as normal. The radiologist's impression of the abdominal CT scan was a distended stomach, with mildly distended multiple segments of small bowel suggestive of small bowel obstruction or ileus and distal esophageal mild dilation and fluid content consistent with vomiting.
DISCUSSION
All of these results were supportive of a diagnosis of sepsis with leukopenia, neutropenia, and metabolic acidosis with respiratory compensation. The diagnosis of sepsis was not solely based on laboratory findings. Serwint, Dias, Chang, Sharkey, and Walker (2005) found that leukopenia or neutropenia alone in the febrile child is not associated with sepsis. Rather, it is the culmination of the clinical judgment, physical findings, and review of the complete blood cell count that identifies significant disease (Serwint et al., 2005). T.B. was leukopenic and febrile, with an altered mental status that further suggested sepsis.
Case Progression
T.B.'s vital signs were stable for the next 30 min. Then, abruptly, T.B. vomited bilious fluid and his heart rate decreased to less than 60/min while his blood pressure became undetectable and his breathing was agonal. Cardiopulmonary resuscitation (CPR) was begun, the patient was placed on a monitor/defibrillator with pediatric pads, and a size 4.0 endotracheal tube was placed by the ED physician using 23.1 mg of ketamine (1.5 mg/kg) for rapid intubation. Placement was verified by two confirmatory methods: chest radiograph and positive colorimetric change identified on the end-tidal CO2 detector immediately following intubation. This was consistent with the American Heart Association's (AHA's) Pediatric Advanced Life Support (PALS) guidelines (AHA, 2011) to confirm endotracheal position in children.
Atropine 7.7 mg (0.5 mg/kg) intravenously was given, and a second 22-gauge PIV catheter was placed in the right antecubital area. A second intravenous fluid bolus was begun (300 ml). The current AHA PALS guidelines (2011) recommend the use of epinephrine for bradycardia associated with poor perfusion. Atropine is indicated when the bradycardia is associated with increased vagal tone. T.B.'s bradycardia was immediately precipitated by vomiting; thus, the use of atropine was consistent with the current guidelines. Intubation may also stimulate a vagal response, with atropine recommended as an adjunct during intubation.
The resuscitation efforts continued for 4 min until T.B.'s blood pressure and heart rate were normalized. A surgeon from a pediatric tertiary care facility was consulted for this critically ill child, because of an abnormal abdominal CT and possible sepsis. He agreed to accept T.B. in transfer and arranged for admission directly to surgery. The critical care pediatric transport team arrived within 15 min. T.B. was transported with 0.9% normal saline fluid boluses infusing through both access sites, as well as the intravenous vancomycin.
Vital signs at the time of transfer were as follows: HR: 124, RR: 25 via ventilator; pulse oximetry: 99%; temperature: 38.2 [degrees]C (100.8 [degrees]F) rectal; and blood pressure: 96/palpable mmHg. A total fluid resuscitation of approximately 600 ml had been delivered at the time of departure. See Figure 1.
Medical Decision Making
Differential diagnoses considered at the time of transfer included sepsis of unknown origin, intussusception with obstruction, volvulus, strangulated hernia, appendicitis, trauma, and meningitis. Although acute abdominal pain in children can be benign in cases such as acute gastroenteritis or mesenteric lymphadenopathy, these were excluded, given the patient's septic presentation. Pediatric patients who present with intractable pain, uncontrolled vomiting, unstable vital signs, altered mental status, and suspicion of an acute abdomen require an emergent surgical consult. The timeliness of consultation and transfer was the result of an established relationship between the community hospital and the pediatric tertiary care facility. The total time of the patient's length of stay in the ED was approximately 1 hr. Although this is the treatment goal for sepsis, the transportation time to the pediatric tertiary care facility was approximately 17 min. The initiation of empirical treatment of sepsis before transfer was an essential component of this child's care.
PEDIATRIC SEPSIS CONSIDERATIONS
Suspicion of Septic Shock
This case presented a pediatric patient with possible septic shock. Multiple professional groups have created evidence-based guidelines that are continuously being reviewed and revised on pediatric sepsis. The AHA with its PALS guidelines (2011), the American College of Critical Care Medicine (ACCM; Brierley et al., 2009), and, on a global platform, the World Federation of Societies of Intensive and Critical Care Medicine (Dellinger et al., 2013) have all published well-accepted algorithms and goal-oriented approaches that are, for the most part, in concert with each other.
Suspicion of septic shock should arise from the "triad of inflammation" with a mental status change (Brierley et al., 2009). The "triad of inflammation" refers to the common signs of benign infection in children: tachycardia, fever, and vasodilation. Sepsis is added to the differential diagnoses when these signs are coupled with irritability, drowsiness, confusion, poor interaction with caregivers, lethargy, or decreased arousal in the pediatric patient (Brierley et al., 2009; Tintinalli, Stapczynski, Ma, Cline, & Meckler, 2011b). These can be difficult to detect in the pediatric patient, but may manifest in a number of behaviors. In this case, the patient had little interaction with caregivers, did not respond to name, was difficult to arouse, and, perhaps most importantly, did not respond appropriately to pain when a PIV catheter was placed. Clinical diagnosis of sepsis is made when a suspected infection is characterized by hypothermia or hyperthermia, and there are clinical signs of inadequate tissue perfusion. The ACCM (Brierley et al., 2009) defines inadequate tissue perfusion into two categories: cold shock (capillary refill more than 2 s, diminished pulses, and mottled cold extremities) and warm shock (flash capillary refill, bounding peripheral pulses, and wide pulse pressure), as well as a general finding of urine output of less than 1 ml/kg/hr. The Surviving Sepsis Campaign (SSC; Dellinger et al., 2013) states that the criteria for systemic inflammatory response syndrome (SIRS), considered the precursor to sepsis, must first be met to establish severe sepsis in a child. This requires either temperature or leukocytic abnormality. Once this has been determined, a child must also have cardiovascular dysfunction, acute respiratory distress syndrome (ARDS), or two or more other organ dysfunctions to be considered in severe sepsis (Dellinger et al., 2013). The definitions of severe sepsis, SIRS, and multiple system organ failure are similar to adults but are age-specific to the pediatric patient (Dellinger et al., 2013).
The role of blood pressure is an important component in the diagnosis and treatment of pediatric sepsis. Hypotension is not required for diagnosis of pediatric septic shock, although its presence is confirmatory (Brierley et al., 2009). As children generally have a lower blood pressure than adults and can maintain an adequate blood pressure with vasoconstriction and increased heart rate, it cannot be used as an endpoint for resuscitation (Dellinger et al., 2013). However, when hypotension does occur, cardiovascular collapse will often follow soon.
Guidelines for Treatment
Time is an important factor for pediatric patients with sepsis. Early aggressive management with fluids, vasoactive agents, and antibiotics within the first hour of arrival is required to reduce the mortality rate in children (Brierley et al., 2009; AHA, 2011; Tintinalli et al., 2011b; Parker, 2009; Dellinger et al., 2013). The goals for emergency department resuscitation mirror the algorithm presented in PALS (AHA, 2011): maintain or restore airway, oxygenation, and ventilation. The endpoints of treatment are capillary refill of 2 s or less, normal pulses with no difference in quality between the peripheral and central pulses, warm extremities, urine output of more than 1 ml/kg/hr, return of normal mental status, normal blood pressures, normal glucose concentration, and normal calcium concentration (Brierley et al., 2009). Pulse oximetry, temperature, cardiac rhythm, blood pressure, pulse pressure, urine output, calcium levels, and glucose levels should all be closely monitored during the emergent phase of resuscitation. The ACCM (Brierley et al., 2009) sets a time goal of 1 hr ("the first hour") in the ED. As noted in T.B.'s case, he was managed in the community emergency department within the first hour; however, an additional "out-of-hospital" time of 17 min during transport must also be considered prior to definitive care at the pediatric tertiary care facility.
Airway Protection
Airway protection is of major importance for children with sepsis and should be rigorously monitored and maintained. In early sepsis, respiratory alkalosis occurs because of centrally mediated hyperventilation. But in late sepsis, hypoxemia and metabolic acidosis occur, placing the patient at high risk for respiratory acidosis secondary to parenchymal lung disease or inadequate respiratory effort, because of altered mental status (Brierley et al., 2009). The decision to intubate should be based on clinical assessment, and waiting for laboratory findings is discouraged. As infants and young children have low functional residual capacity, early intubation in severe sepsis may be warranted (Dellinger et al., 2013). Up to 40% of cardiac output can be consumed by work of breathing, and, therefore, intubation and mechanical ventilation may reduce or reverse septic shock (Brierley et al., 2009). Etomidate is not recommended, as the adrenal suppression effect could be detrimental to a pediatric patient with sepsis (Brierley et al., 2009). This differs from the adult patient with sepsis, in whom etomidate's benefits in critical airway management are thought to outweigh the adrenal suppression (Tintinalli et al., 2011b). The ACCM (Brierley et al., 2009) suggests ketamine with pretreatment atropine and a benzodiazepine postintubation as the induction/sedation regimen of choice to maintain cardiovascular integrity.
Fluid Resuscitation
Suggested fluid resuscitation starts at 20-ml/kg bolus, either by intravenous push or by rapid infusion/pressure bag, with up to three or four boluses within the first hour (Brierley et al., 2009; AHA, 2011; Dellinger et al., 2013). As much as 200 ml/kg can be delivered in the absence of pulmonary edema, rales, a gallop rhythm, or hepatomegaly if initial fluid resuscitation amounts do not improve clinical findings (Brierley et al., 2009). Assessment of the child's lung sounds, pulse oximetry, heart sounds, and vital signs must be ongoing during fluid resuscitation. A D10 isotonic solution can be started at a maintenance rate as well to prevent hypoglycemia (Brierley et al., 2009). Historically, there have been discussions whether crystalloid or colloid fluid resuscitation is more advantageous. The timeliness of fluid resuscitation is of greatest importance and either solution can be used as long as it is used promptly. However, one randomized controlled trial does find that although the crystalloid and colloid solutions do not change the mortality of cases, children who receive lactated Ringers do have longer recovery times (Ngo et al., 2001). The SSC (Dellinger et al., 2013) suggests the use of isotonic crystalloids and/or albumin in initial fluid resuscitation. The AHA's PALS algorithm (2011) suggests initial treatment only with crystalloid solution.
Inotropes and Vasopressor Use
When hemodynamic stability is not achieved by fluid resuscitation alone, vasopressors and/or inotropes should be administered. If the patient is in warm septic shock (hypotensive, vasodilated), norepinephrine should be considered, and if the patient is in cold septic shock (hypotensive, vasoconstricted), epinephrine should be considered (Brierley et al., 2009; AHA, 2011; Dellinger et al., 2013). Dopamine can be used and titrated until clinical examination shows improvement in the child who remains normotensive but has persistent perfusion deficits (AHA, 2011). The use of hydrocortisone, milrinone, nitroprusside, and/or dobutamine is discussed in the sepsis guidelines as adjuncts to treatment primarily for use after admission to an intensive care unit, or "beyond the first hour" (Brierley et al., 2009; AHA, 2011).
The AHA (2011) suggests consideration of central venous access for administration of vasopressors or inotropic medications in the patient with sepsis. However, as a practical matter, it may be time-consuming and resource-intensive to establish central access in an infant or a child during the first critical hour in the ED. These medications can be given peripherally until central access is established, with frequent assessment of the PIV site for infiltration (AHA, 2011; Parker, 2009; Dellinger et al., 2013).
Relevance for Advanced Practice Nurses
It is important for the health care provider in the ED to be aware of the sometimes subtle signs of impending sepsis or septic shock. As these guidelines are established and revised, improvement in mortality rates has been seen globally. In the 1980s to the 1990s, mortality rates for pediatric septic shock were more than 50%, but with the implementation of such guidelines, the rate has decreased to 20%-30% (Kutko et al., 2003). There are 400,000-500,000 cases of gram-negative sepsis in children per year globally (Kutko et al., 2003). In another investigation, Watson et al. (2003) found 42,364 cases of pediatric severe sepsis per year nationally (in the United States), or 0.56 cases per 1,000 cases per year. Males have a significantly higher incidence than females: 0.6 per 1,000 versus 0.52 per 1,000 cases per year (Watson et al., 2003). The mortality rate of pediatric patients with severe sepsis is 10.3% in the United States (Watson et al., 2003).
Advanced practice nurses in the ED often encounter sick children, and scrupulous examination and history taking is essential for proper diagnosis. Rapid identification by the triage staff can influence the outcome as well. In T.B.'s case, his new-onset fever and singular vomiting episode may not have warranted immediate attention, as this could have been seen as a common viral infection that could be treated in the outpatient setting. The importance of the initial visual assessment by utilization of the PAT was demonstrated in this case. T.B.'s initial abnormal appearance but normal work of breathing and circulation to the skin indicated a central nervous system/metabolic dysfunction. The associated management priorities included supplemental oxygen, measurement of pulse oximetry, glucose, and other laboratory and radiographic evaluations while considering possible etiologies (Dieckmann, Brownstein, & Gausche-Hall, 2010). There is also the importance of elapsed time in pediatric patients. T.B. was able to compensate metabolically for quite awhile, but his condition quickly declined shortly after his arrival in the ED. As the aforementioned evidence-based guidelines strongly suggest, if a suspicion of sepsis is part of an advanced practice nurse's differential, empirical therapy, with aggressive resuscitation efforts, is warranted until otherwise ruled out or contraindicated.
Critique of the ED Care
The ED care provided closely follows the SSC (Dellinger et al., 2013), ACCM (Brierley et al., 2009), and AHA PALS (2011) guidelines as described previously. Aggressive fluid resuscitation was conducted, ketamine was used for intubation, and broad-spectrum antibiotic therapy was started immediately following collection of blood cultures. Perfusion was restored and vascular stability was maintained without the need for titrated inotropes, although atropine was required initially. In this small community hospital, time to definitive care was a priority. A complete pediatric sepsis workup also includes a lumbar puncture (LP) for analysis of cerebrospinal fluid. The priority in this case was expeditious transfer to a tertiary care facility and the LP was deferred. The diagnostic studies point to a likely abdominal etiology for T.B.'s condition; however, bacterial meningitis remained a part of the differential diagnoses. Empirical antibiotic therapy and stabilization interventions were already initiated, and the results of the LP would not have affected the immediate treatment plan. This fact was important to the care during transport of T.B. when droplet isolation was indicated until bacterial meningitis was ruled out. Additional diagnostic tests indicated by T.B.'s presentation include a fecal occult blood test, serum lactate, and arterial or venous blood gas analysis. In some institutions, the lactate level can be drawn as a "point-of-care" test, which may have been useful in this case.
Access to Care
The ED setting described previously was a small community hospital in an urban area where access to care was limited. Although T.B.'s mother was uninsured, the state's department of health care and family services provides medical insurance to all children in this state as universal access to emergency medical care. A medical record review revealed that T.B. had been seen in this ED three times since his birth for primary care treatment including vaccines and otitis media. With each prior visit, a referral to a pediatrician was given, but the mother stated that she did not follow up with the pediatrician because there was a 3-month waiting list for annual checkups. She explained that the community ED was nearby and always accessible and that she knew that she would not receive a bill for his medical care.
Maltreatment Considerations
The immediate general impression of the patient was that he appeared poorly cared for as evidenced by soiled clothes and lack of cleanliness. The mother's indifference to the situation at the time of arrival was an additional concern to the ED staff. As T.B.'s condition rapidly declined, his mother's coping mechanism began to emerge as denial. When placing the first PIV catheter, the mother stepped out of the room and said, "I can't watch this." She placed a chair outside the door and sat down. A nurse sat with the mother and explained the treatment while encouraging her to return to the room and comfort the child. The mother declined. The mother's affect was flat throughout the time spent in the ED. During cardiopulmonary resuscitation efforts, the mother asked, "So should I get him a flu shot next year?" Multiple personnel attempted to convey the seriousness of the situation, but the mother did not appear to comprehend.
After the patient was safely transported to the awaiting hospital, the medical staff held an informational debriefing. At that time, it was determined that the boy's appearance and physical condition were not congruent with the history given by the mother. On the basis of these findings and the mother's affect during the event, it was decided to initiate a report to the state's department of children and family services.
PATIENT SUMMARY AND CONCLUSION
The patient presented with clinical manifestations of sepsis, as well as a case of suspected child maltreatment (neglect). This case study displayed the signs and symptoms consistent with septic shock. The importance of thorough history taking and judicious physical assessment with rapid, definitive care were especially important in this case. The application of evidence-based guidelines is imperative in the management of pediatric patients presenting with sepsis.
REFERENCES