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Case 23
Author: Steve Miller, M.D., Columbia University

Learning Objectives
Students will be able to describe:

1. How to determine if a patient is emergently ill.

2. The differential diagnosis of a lethargic child.
3. The different types of shock.
4. The actions needed to perform the ABCs.
5. The principles of choosing the right fluids.
6. The principles of effectively breaking bad news to a patient and a patient's
7. The principles of phone triage.

Summary of clinical scenario: The father of 15-year-old Sarah calls concerned

because she has a fever of 103 Fahrenheit and is out of it. He also says she is
breathing pretty fast, and looks pale. She has not had anything to eat or drink all
day and has not urinated since early in the morning. Her father is advised to bring
Sarah into the emergency department. En route to the hospital in the ambulance,
Sarah develops a petechial rash on her trunk and arms. Physical exam reveals
nuchal rigidity, along with tachycardia and decreased perfusion. Sarah is given
boluses of intravenous fluids and parenteral antibiotics for meningococcal sepsis.

Key Findings from History
Decreased urine output

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Petechial rash
Key Findings from Physical
Nuchal rigidity

Diabetic ketoacidosis
Central nervous system tumor
Differential Diagnosis Meningitis
Renal failure

Gram stain positive for

Key Findings from Testing gram-negative diplococci,
consistent with meningococcus

Final Diagnosis Meningococcemia

Case highlights: The case teaches when and how to triage over the phone, and
what information to gather before advising a patient to be seen in the emergency
department. Once Sarah arrives at the hospital, the case focuses on how to
determine level of consciousness, assess airway, breathing, and circulation, and
determine if a patient is in shock. Students learn how to manage a patient in
shock and how to administer fluids to maintain perfusion. Having determined that
Sarah has meningococcemia, students learn how to treat the disease and how to
break the bad news to her parents. Multimedia features include photographs and
drawings illustrating how to open a childs airway.

Key Teaching Points


Definition: Inadequate delivery of substrates and oxygen to meet the metabolic

needs of tissues.In the pediatric age group, shock is not a blood pressure
diagnosis; children can maintain a normal blood pressure until they are in
profound shock.

Compensatory mechanisms: Children in shock have excellent compensatory

mechanisms to maintain tissue perfusion, including:

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Increased heart rate (tachycardia): When stroke volume decreases, the

body tries to maintain cardiac output by increasing the heart rate.
Increased systemic vascular resistance (vasoconstriction)
Increased heart contractility (more complete emptying of the ventricles)
Increased venous tone (greater blood return to the heart)
Increased respiratory rate (tachypnea): The bodys attempt to compensate
for the metabolic acidosis caused by decreased oxygen perfusion of the
tissues and cells.

Types: Hypovolemic and septic shock are most common causes of shock in

Hypovolemic shock: Inadequate fluid intake to compensate for fluid loss

(e.g., vomiting, diarrhea, hemorrhage).
Signs and symptoms: Mental status changes, tachypnea, tachycardia,
hypotension, cool extremities, oliguria.
Septic shock: Infectious organisms release toxins that affect fluid
distribution and cardiac output. May be bacterial, viral, orin
immunocompromised patientsfungal. Patient needs repeated boluses of
fluid. May need inotropes to enhance cardiac contractility and vasopressors
(epinephrine or dopamine) to raise blood pressure.
Signs and symptoms: May present initially as compensated or warm
shock (warm extremities, bounding pulses), tachycardia, tachypnea,
adequate urination, mild metabolic acidosis
Cardiogenic shock: Rare in children; may be associated with severe
congenital heart disease, dysrhythmias, cardiomyopathy, or tamponade.
Signs and symptoms: Cool extremities, delayed capillary refill (> 2
seconds), hypotension, tachypnea, increasing obtundation, decreased
urine output
Distributive shock: Includes neurogenic shock and anaphylactic
shockwhere vasodilation, increased capillary permeability, and third-space
fluid loss results in intravascular hypovolemia.

Principles of telephone triage: It is highly risky to offer advice over the
telephone to a patient not known to the physician. Even if the physician does
know the patient, caution must be used. Keep these guidelines in mind:

As a student or resident, never give phone advice on your own without

supervision from an attending.
Let the patient or parent know that a physician will see the patient in the
office the next day, or that the staff in the emergency department can see
the patient immediately, but that no medical decisions can be made about a
patient who has not been seen.
You may answer follow-up questions from a patient or patients parent
whom you have seen previously if the questions are about the same
problem (e.g., how long do I need to keep my child on his medications; is

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he contagious, etc.). If the family calls and asks about a new problem or
condition, then the same rules apply as if this was a patient you had never
seen before.
If advice is given, it must be documented.

Criteria for recommending immediate medical attention:

Consider a patient to be dangerously ill if the vital life functions of delivering

oxygen and nutrients to end organs are impaired.
Assess functioning of the brain, skin, kidneys, and lungs.
Also determine if there are underlying conditions that place the patient at
risk (e.g., sickle cell disease, human immunodeficiency virus, neutropenia,
diabetes mellitus).

Always start with the ABCs: It is essential to look first for anything that
reduces oxygen and critical nutrients to cells:

Airway: If patient does not seem to be moving air with breathing, first check the
airway and determine if there is an obstruction. May need to:

Position the neck

Perform a jaw thrust (if concern about head trauma)

Breathing: Observe effort and rate of breathing, how the patients lungs sound,
and if they are well oxygenated:

Look at the chest to determine the respiratory rate.

Listen to breath sounds for wheezes, rales, rhonchi, diminished breath
Use a pulse oximeter to rapidly assess the oxygenation of the patient (may
be difficult due to vasoconstriction)


Tachycardia is first and most subtle sign of possible inadequate perfusion.

Check capillary refilla sensitive sign of hypovolemia.

In reality, the ABCs also include a "D" and "E:

Disability and Dextrose

Disability: A quick neurologic assessment to uncover signs of increased

intracranial pressure or possible poisoning:
Assess mental status.
Examine pupils, including their size and reaction to light.
Pupillary changes, especially unequal pupils, are a sign of
increased intracranial pressure.
May find a clue to a toxidrome (such as lethargy and pinpoint
pupils, suggesting opioid ingestion).

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Dextrose: This is a reminder to check for hypoglycemia, a condition that

must be diagnosed and treated immediately.

Exposure and Environment: Expose and examine all parts of the patient, and
keep the patient warm during the evaluation

Giving bad news:

Make sure the patient and family are comfortable and have support people
with them.
Ask what the patient or parent knows and what their concerns are.
Tell them the diagnosis and what the treatment is without using medical
Tell them the prognosis.
Be honest and give some way to offer hope.
If the situation is bleak, give the patient and family short-term goals and

Differential diagnosis
Altered mental status or lethargy in a child:

1. Meningitis: Fever in child with altered mental status highly suggestive of

meningitis. Tachypnea and decreased urine output consistent with
associated shock. Hallmark symptoms of meningitis are fever, headache,
stiff neck, altered mental status, and photophobia (although many patients
present with only two or three of these clinical indicators).
2. Sepsis: Fever and lethargy are prominent symptoms with sepsis.
Tachypnea and decreased urine output are also commonly seen.
3. Diabetic ketoacidosis (DKA): Patients in DKA can present with lethargy
and tachypnea. Urine output would be increased, not decreased.
4. Renal failure: Associated acidosis could lead to tachypnea and lethargy.
May be primary or secondary (i.e., due to another etiology).
5. Ingestion: Overdoses can often cause otherwise unexplained lethargy.
Depending on toxin, decreased urine output and tachypnea may be seen.
6. Central nervous system (CNS) tumor: Increased intracranial pressure
due to mass effect from a CNS tumormay lead to lethargy and tachypnea.
7. Hypoglycemia: Low blood sugar may cause lethargy and altered mental
8. Encephalitis: Often caused by viral infections in children. Presents with
altered mental status and fever.
9. Pneumonia: Fever and tachypnea would be found with pneumonia, but
altered mental status would be uncommon unless patient was severely

Petechial rash, fever, lethargy, and shock:

1. Meningococcal sepsis: Whenever a patient presents with fever and

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petechiae, meningococcal sepsis must always be at the top of the

differential diagnosiseven if the patient otherwise looks well. A blood
culture must be collected and antibiotics given until the disease can be
definitively ruled out. The fatality rate in all ages is 10%, 25% in
adolescents. Sequelae, occurring in 1119% of patients, include hearing
loss, neurologic disability, digit or limb amputations, and skin scarring.
2. Kawasaki disease: Fever and rash are associated signs. Mucocutaneous
lesions include a "strawberry" tongue and dry, red, cracked lips. There is
diffuse erythema of the oral cavity and erythema and/or edema of
hands/feet and a polymorphic truncal rash.
3. Toxic shock syndrome: Cause of fever and a sunburn-looking rash that
might feel rough to the touch (like sandpaper).
4. Scarlet fever: This starts as a finely punctate pink-scarlet exanthem that
appears on the upper trunk 1248 hours after onset of fever. As rash
spreads to the extremities, it becomes confluent and feels like sandpaper.
Linear petechiae (Pastias sign) are evident in body folds. Pharynx is beefy
red and the tongue is initially white and rough (strawberry tongue), later
becoming bright red.

Complete blood count (CBC) with differential and platelets, blood/urine
culture,and gram stain: These are needed to rule sepsis in or out as soon as
possible. Also, blood and urine cultures must be obtained before starting

Chemistries (sodium, potassium, chloride, bicarbonate, blood urea

nitrogen, creatinine, glucose): Hypoglycemia and other electrolyte imbalances
are common causes for altered mental status. Their levels must be checked.

Lumbar puncture: Obtain once patient is stabilized.

Initial emergency management of shock

Intravascular volume replacement is the priority, even when there is a risk

of increased intracranial pressure.
In most patients, a fluid bolus of 20 cc/kg normal saline should be given
rapidly via intravenous or intraosseous line.
Replace fluid volume replacement with isotonic saline, not hypotonic.
If patient continues to have poor perfusion and shock after fluid
resuscitation, may need vasoactive agents.

Reference: Behrman RE, Kliegman RM, Jenson HB, Stanton BF. Nelson Textbook
of Pediatrics, 18th Ed. Philadelphia, Pennsylvania. 2007

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Indications for intraosseous (IO) access:

In an emergency, if a peripheral intravenous line cannot be placed within 90

seconds, an IO line (via a needle inserted into the marrow cavity of a long
bone) should be placed. This provides fast and easy access for any fluid.
Substances injected into the marrow are absorbed almost immediately into
the general circulation.
Placing a central line (femoral, subclavian, internal jugular) takes
longer than an IO, but may be acceptable in older child, adolescent, or
Arterial line: Arteries cannot tolerate the massive fluids required for

Antibiotics: The most appropriate antibiotic treatment for meningococcemia is

penicillin G. Calculating doses for teenagers and large children can be tricky.
Doublechecking calculations with the formulary is an important step to preventing
mistakes when prescribing medications.

Infection control: Household, childcare, and nursery schoolcontactsand any

health care workers having close contact with the patient before she/he received
antibioticsshould receive prophylaxis (ciprofloxacin for adults and rifampin or
ceftriaxone for children).


For the general population, the tetravalent meningococcal conjugate vaccine

(MCV4) is given intramuscularly to children ages 1118, usually at the
routine preadolescent visit.
A booster dose should be given at age 16, before the peak in increased risk.
(Adolescents who receive their first dose of MCV4 at or after age 16 years
do not need a booster dose.)
College freshmen living in dorms are considered high risk and should
receive a dose of the MCV4 vaccine within 5 years before starting college.
The MCV4 vaccine is not recommended for children < 2 years of age.
There are guidelines for certain other situations in high-risk children and
adults in which administration of MCV4 is recommended.

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