Pediatrics · Year 3 · from Pediatrics
Case 1: Pediatric Septic Shock
Patient Demographics
- Age: 3-year-old female
- Sex: Female
Chief Complaint
"She's been sick with a fever and is now really lethargic."
History of Present Illness
A 3-year-old previously healthy girl is brought to the emergency department by ambulance after her parents found her difficult to arouse this morning. She has had fever to 40C for 2 days with runny nose and cough. Last night she was still drinking fluids, but this morning she would not wake up normally and has been "floppy." She has not eaten in 24 hours and has had decreased wet diapers. She has no significant past medical history and is up to date on vaccinations. There are no sick contacts with serious illness, and she attends daycare.
Physical Examination
- Vital Signs: Temperature 39.8C, HR 180 bpm, RR 42/min, BP 72/40 mmHg, SpO2 94% on room air
- Weight: 14 kg
Pediatric Assessment Triangle:
- Appearance: Abnormal - lethargic, weak cry, poor tone
- Work of Breathing: Mildly increased - tachypnea without retractions
- Circulation: Abnormal - pale, mottled
- General: Lethargic, arouses only to painful stimuli
- Skin: Mottled trunk and extremities, cool distal extremities, delayed capillary refill (5 seconds), non-blanching petechial rash on trunk and legs
- HEENT: Dry mucous membranes
- Cardiovascular: Tachycardic, weak pulses
- Respiratory: Tachypneic, clear breath sounds
- Neurologic: GCS 11 (E3V3M5), no focal deficits, no meningismus
Laboratory Findings
- Blood gas (venous): pH 7.22, pCO2 28, HCO3 12, lactate 6.8 mmol/L
- CBC: WBC 22,000/uL with 85% neutrophils, 12% bands; Platelets 85,000/uL
- Glucose: 52 mg/dL
- CRP: 18 mg/dL
- Blood culture: Pending
- Procalcitonin: 45 ng/mL (markedly elevated)
Diagnosis
Septic shock (cold shock phenotype) - presumed bacterial meningococcemia
Clinical Reasoning
This child presents with septic shock evidenced by: tachycardia, hypotension (BP 72/40, <5th percentile for age), poor perfusion (mottled skin, delayed capillary refill, weak pulses), altered mental status, and metabolic acidosis with elevated lactate. The phenotype is "cold shock" (vasoconstriction, cool extremities, weak pulses, prolonged cap refill) rather than "warm shock" (vasodilation, bounding pulses, flash cap refill). The petechial/purpuric rash with this presentation is highly concerning for meningococcemia (Neisseria meningitidis). This is a medical emergency with high mortality requiring immediate recognition and aggressive resuscitation.
Management
First Hour Sepsis Bundle:
- Recognize shock: Altered mental status + signs of poor perfusion
- IV access: Establish 2 large-bore IVs or IO if unable; do not delay treatment
- Fluid resuscitation:
- 20 mL/kg (280 mL) normal saline bolus over 5-10 minutes
- Reassess; repeat up to 60 mL/kg in first hour if shock persists
- Goal: Improved mental status, cap refill <2 sec, normalized pulses
- Antibiotics within 1 hour:
- Ceftriaxone 100 mg/kg (max 4g) IV
- Consider vancomycin if MRSA risk
- Glucose: Correct with D10W 2-4 mL/kg for hypoglycemia
- Vasoactive medications (if fluid refractory):
- Epinephrine 0.05-0.3 mcg/kg/min IV/IO (first-line for cold shock)
- Reassess frequently: Every 5 minutes during resuscitation
- Central access: For ongoing vasopressor administration
- Stress-dose steroids: Consider hydrocortisone if catecholamine-refractory shock
Clinical Image
Image Description: Characteristic petechial and purpuric rash seen in meningococcemia, demonstrating the non-blanching lesions that can rapidly progress to purpura fulminans in severe sepsis.
Source: Wikimedia Commons URL: https://commons.wikimedia.org/wiki/File:Meningococcemia.jpg License: CC BY-SA 3.0