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Learning Objectives:

Role (CANMEDS, Other) Objective

Recognize the presence of septic
Medical Expert
shock
Recognize the manifestations of
Medical Expert
meningococcemia
Treat septic shock
Medical Expert
appropriately
Choose an item. Team work (scale)
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Scenario Information
History of Presenting Illness/Situation
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 18 month old child in ED.
 Woke up from nap with fever, fussiness, and lethargy.
He is pale, refuses to drink, and looks bad according to mom

Further History:
If asked- Child appeared well 5 hours ago, maybe a bit less playful than usual, only one wet diaper in the last 12 hours. Mom noticed a
fine rash on face and chest on arrival to hospital. Mom runs a small daycare in her home.

PMH: recurrent ear infections

No meds, NKDA, parents do not believe in immunizations
FmHx unremarkable.

Triage vital signs : HR 190, RR 36 grunting, BP 87/33, T 38.8 C, sats 98% on R/A (if asked)
Estimated weight 12 kg (if asked)

Session Information/Requirements
Location: Emerg
 Simulator: Laerdal SimBaby
MakeUp: petechial rash
Confederates/Actors: Mother
Equipment: Click here to enter text.
Access: IO
Drugs: fluids, Antibiotics, Pressors (Dopamine), RSI
Xray: Click here to enter text.

Scenario

Expected Actions and

Time Scenario Flow Vital Sign Changes Actor and Patient Script
Transitions
Temp 40C, HR 170, BP
Stage 1 76/45, RR 35, O2 sat
Assessment Assess baseline vitals 92%. Estimated weight Place monitors on pt,
0-1 min 12kg.

1. 100% O2
2. Monitors: HR, RR,
General Appearance: Pale, BP checks every 2-
lethargic, tachypneic, grunting, 4 minutes.
mottled with cool extremities 3. Tryt IV - fail
Airway: patent 4. Obtain IO access.
Breathing: tachypneic, 5. Administer IV
grunting respirations, lungs glucose (1cc/kg
clear D50, 2cc/kg D25 or
Circulation: tachycardic with 5cc/kg D10) Accucheck: 1.1
regular rhythm. Cap refill 4-5 6. fluid resuscitation –
Stage 2 iStat Results:
sec. Weak distal pulses. Cold 20cc/kg NS bolus
Fluid Resus. VBG: 7.13/30/-/12 -13
1-5 min extremities now, and prepare Na 139, K 4.3
D: lethargic, responds only to for more fluids. Ca 2.1
painful stimuli (E -2, V – cries 7. Bloodwork: HGB 129
moans w/ pain 2, M- purposeful VBG, lytes,
withdrawal 5; GCS 9), PERL 3- BUN/CR, CBC,
4 mm PTT/INR.
If asked: fine pinpoint petechiae Blood culture,
on chest, abdomen, & face urine culture.
Rest of exam unremarkable 8. Start Antibiotics -
Vancomycin/
Ceftriaxone
 RSI – atropine,
ketamine or etomidate,
succinylcholine
Circulation: 2nd and 3rd
bolus of 20 cc/kg NS,
Airway: Patent
FFP, cryoprecipitate VBG pH 7.1, pCO2 25,
Breathing: Tachypneic, shallow
Start Dopamine 10 Bicarb 10, BE – 15.
resps
mcg/kg/min – titrate up Na 144, K 4.5, Cl 110,
Circulation: Tachycardic,
Stage 3 HR 180, BP 60/30, RR 35, to 20 mcg/kg/min BUN 15, Cr 130.
mottled. CRT now 5 seconds.
RSI @ T. 40.1C, sat 94% in Failure of Dopamine: Glucose 1.2.
Face/lips pale.
Inotropes 100% O2  Cold shock: WBC 15, Neutrophils 8,
5-10 min Neuro: Does not arouse to
epinephrine 0.1- Bands 4, Plt 100, Hb
verbal stimuli difficult to arouse
1 mcg/kg/min 95.
by touch, arouses to painful
 Warm shock: INR 1.8, PTT 55
stimuli
norepi 0.1-1
mcg/kg/min
0.3 x wt/50cc  1 ml/hr
= 0.1 mcg/kg/min
ICU consult/Transfer

Airway: Intubated Begin chest If effective

HR: 75 (on monitor but not
Stage 4 Breathing: bagged
palable), BP not obtainable, compressions compressions and epi
PEA Circulation: No palpable pulses.
RR (bagged), T 38, sat not Give Epi 1:10,000 0.01 given, has return of
10-15 min Very mottled. CRT >5sec
picking up mg/kg pulses
Neuro: unresponsive
Airway: Intubated HR 140, BP 75/45, RR
Stage 5 Breathing: bagged
bagged, T. 39.1C, sat CXR
Recovery Circulation: Weak pulses. CRT
15-18 min >5sec 94% in 100% O2 ICU transfer
Neuro: unresponsive

Septic Shock Learning Points:

1. Recognize the syndrome of fever and petechiae as a medical emergency

Fever/Petechiae may be signs of overwhelming infection
Caretakers must observe strict respiratory precautions
Antibiotics must be given immediately after blood culture is taken. Do not delay for urine or CSF
Immediate intervention may be life-saving
2. Understand that systolic blood pressure can be preserved late into the course of shock in children
Children’s hearts increase C.O. by increased rate, not pressure.
Tachycardia is a much earlier indicator of shock than hypotension. But tachycardia is nonspecific. Must be taken in the context of
hypovolemic indicators: skin color, temp, turgor. Cap refill, pulse

3. Know that early and aggressive fluid resuscitation and inotropy can be lifesaving
Fluids as isotonic crystalloids must be given aggressively in septic shock (up to 60 mg/kg). Bacterial endotoxin inhibits cardiac contractility.
Consequently, dopamine improves inotropy and therefore cardiac output.
iStat

VBG 7.13/30/-/12, BE -13

Glucose 1.2

Na 139
K 4.3

Ca 2.1

HGB 129
Lab Values

VBG pH 7.1, pCO2 25, Bicarb 10, BE – 15.

Na 144, K 4.5, Cl 110,

BUN 15, Cr 130.

Glucose 1.2.

WBC 15,
Neutrophils 8, Bands 4, Plt 100, Hb 95.

INR 1.8, PTT 55