# Clinical Cases: Pediatric Emergencies

## 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:**
1. **Recognize shock:** Altered mental status + signs of poor perfusion
2. **IV access:** Establish 2 large-bore IVs or IO if unable; do not delay treatment
3. **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
4. **Antibiotics within 1 hour:**
   - Ceftriaxone 100 mg/kg (max 4g) IV
   - Consider vancomycin if MRSA risk
5. **Glucose:** Correct with D10W 2-4 mL/kg for hypoglycemia
6. **Vasoactive medications (if fluid refractory):**
   - Epinephrine 0.05-0.3 mcg/kg/min IV/IO (first-line for cold shock)
7. **Reassess frequently:** Every 5 minutes during resuscitation
8. **Central access:** For ongoing vasopressor administration
9. **Stress-dose steroids:** Consider hydrocortisone if catecholamine-refractory shock

### Clinical Image
![Child with petechial rash of meningococcemia](case_01_image.jpg)

**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

---

## Case 2: Status Epilepticus

### Patient Demographics
- **Age:** 5-year-old male
- **Sex:** Male

### Chief Complaint
"He's been having a seizure for 10 minutes."

### History of Present Illness
A 5-year-old boy with a history of epilepsy (on levetiracetam) is brought to the emergency department by EMS after having a generalized tonic-clonic seizure that started at home approximately 15 minutes ago. His mother gave rectal diazepam (0.5 mg/kg) at home 5 minutes after seizure onset, but the seizure has not stopped. EMS reports continuous seizure activity en route. He had a cold for the past 2 days but no fever. His mother thinks he may have missed his evening medication last night. His last documented seizure was 8 months ago.

### Physical Examination
- **Vital Signs:** HR 165 bpm, RR 28/min (assisted), BP 135/85 mmHg, SpO2 88% on room air, Temperature 37.2C
- **Neurologic:** Active generalized tonic-clonic seizure activity; bilateral rhythmic jerking of all extremities; eyes deviated to the right; unresponsive to voice or painful stimuli

### Immediate Actions Taken
- **Time 0 (ED arrival, 15 min into seizure):**
  - Airway positioning, suction secretions
  - Bag-valve mask ventilation with 100% O2, SpO2 improves to 95%
  - IV access obtained

### Diagnosis
**Status epilepticus**

### Clinical Reasoning
Status epilepticus is defined as continuous seizure activity lasting 5 or more minutes, or recurrent seizures without return to baseline. This child has been seizing for >15 minutes, meeting criteria for established status epilepticus. He has received one dose of benzodiazepine without effect. Risk factors include underlying epilepsy and possible medication non-adherence. Status epilepticus is a medical emergency because prolonged seizure activity causes neuronal injury and is associated with increased morbidity and mortality. Time is critical - the longer a seizure continues, the more refractory it becomes to treatment.

### Management Protocol

**Stabilization Phase (0-5 minutes):**
- Airway, breathing, circulation
- Obtain IV/IO access
- Check glucose (result: 85 mg/dL - normal)
- Continuous monitoring

**First-Line Anticonvulsant (5-10 minutes):**
- Lorazepam 0.1 mg/kg (2 mg) IV push
- Reassess in 5 minutes
- Seizure continues

**Second Dose Benzodiazepine (10-15 minutes):**
- Repeat lorazepam 0.1 mg/kg (2 mg) IV
- Seizure continues at 20 minutes total

**Second-Line Anticonvulsant (15-20 minutes):**
- Options: Fosphenytoin, levetiracetam, or valproate
- Fosphenytoin 20 mg PE/kg IV over 10-15 minutes
- Monitor BP and ECG during infusion

**Ongoing status at 30+ minutes = Refractory Status Epilepticus:**
- Consider third-line agents: phenobarbital 20 mg/kg
- Prepare for RSI and continuous EEG monitoring
- ICU admission

### Outcome
Seizure terminated after fosphenytoin loading. Total seizure duration approximately 25 minutes. Patient intubated for airway protection given prolonged post-ictal state. Admitted to PICU for monitoring.

### Clinical Image
![EEG showing seizure activity](case_02_image.jpg)

**Image Description:** Electroencephalogram (EEG) tracing demonstrating generalized epileptiform discharges during a seizure, showing the characteristic rhythmic waveform patterns seen in status epilepticus.

**Source:** Wikimedia Commons
**URL:** https://commons.wikimedia.org/wiki/File:EEG_seizure.svg
**License:** CC BY-SA 4.0

---

## Case 3: Pediatric Anaphylaxis

### Patient Demographics
- **Age:** 8-year-old male
- **Sex:** Male

### Chief Complaint
"He ate a cookie with peanuts and can't breathe."

### History of Present Illness
An 8-year-old boy with a known peanut allergy is brought to the emergency department by his father. At a birthday party 20 minutes ago, he ate a cookie that he didn't know contained peanut butter. Within 5 minutes, he developed itchy hives on his arms and face. He then developed swelling of his lips and throat tightness. He has been coughing and wheezing. His father administered one dose of diphenhydramine at the party but did not have an epinephrine auto-injector available. The symptoms have been rapidly progressing.

### Physical Examination
- **Vital Signs:** HR 145 bpm, RR 36/min, BP 78/50 mmHg (low for age), SpO2 91% on room air
- **General:** Anxious, appears in distress, hoarse voice
- **Skin:** Diffuse urticarial wheals on trunk and extremities, flushed
- **HEENT:** Angioedema of lips and tongue; oropharynx shows uvular edema
- **Respiratory:** Stridor audible without stethoscope, bilateral wheezing, increased work of breathing with retractions
- **Cardiovascular:** Tachycardic, weak peripheral pulses

### Diagnosis
**Anaphylaxis with respiratory and cardiovascular involvement**

### Clinical Reasoning
This patient meets criteria for anaphylaxis with involvement of multiple organ systems:
1. **Skin/mucosa:** Urticaria, angioedema
2. **Respiratory:** Stridor (upper airway), wheezing (lower airway), hypoxia
3. **Cardiovascular:** Hypotension, tachycardia

The known peanut exposure provides the trigger. Anaphylaxis is a clinical diagnosis requiring immediate treatment. The presence of hypotension and respiratory compromise indicates severe anaphylaxis. Diphenhydramine alone is NEVER adequate treatment for anaphylaxis - EPINEPHRINE is the first-line and life-saving medication.

### Management

**Immediate Actions:**
1. **EPINEPHRINE IM:** 0.01 mg/kg of 1:1,000 (1 mg/mL)
   - Weight 25 kg x 0.01 mg/kg = 0.25 mg
   - Give 0.25 mg (0.25 mL) IM in lateral thigh
   - May repeat every 5-15 minutes if symptoms persist

2. **Position:** Supine with legs elevated (unless respiratory distress requires upright position)

3. **Supplemental oxygen:** High-flow oxygen via non-rebreather mask

4. **IV access and fluids:** 20 mL/kg normal saline bolus for hypotension

5. **Adjunctive medications:**
   - Albuterol nebulizer for persistent wheezing
   - H1 antihistamine (diphenhydramine 1 mg/kg IV)
   - H2 antihistamine (ranitidine 1 mg/kg IV)
   - Methylprednisolone 1-2 mg/kg IV (prevents biphasic reaction, but NOT first-line)

6. **Monitor:** Continuous cardiac and respiratory monitoring

7. **Prepare for airway management:** Have intubation equipment ready

### Response to Treatment
After IM epinephrine:
- HR decreased to 110 bpm
- BP improved to 95/60 mmHg
- Stridor resolved
- Wheezing improved with albuterol
- Urticaria beginning to fade

### Disposition
- **Observation:** Minimum 4-6 hours for biphasic reaction (can occur in up to 20%)
- **Discharge planning:**
  - Prescription for 2 epinephrine auto-injectors
  - Demonstrate proper use before discharge
  - Anaphylaxis action plan
  - Referral to allergist
  - Medical alert bracelet recommended
  - School action plan

### Clinical Image
![Epinephrine auto-injector technique](case_03_image.jpg)

**Image Description:** Demonstration of proper technique for intramuscular epinephrine administration using an auto-injector in the anterolateral thigh, the first-line treatment for anaphylaxis.

**Source:** Wikimedia Commons
**URL:** https://commons.wikimedia.org/wiki/File:Epipen.jpg
**License:** CC BY-SA 4.0