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Case Study: Paediatrics
A 5 month old male baby was brought into the Emergency Department by his mother.

He is lethargic and limp with occasional aggravated-type crying. The conscious state is alternating between being asleep and agitated crying. He was not quite himself yesterday according to the family.  Today he went off food three hours ago, quite rapidly and since then has been as we see him now.

There is no past history, normal vaginal delivery and immunizations up to date.

Vitals are:

1. PR 234 bpm
2. Temperature 38°
3. BP – trouble getting
4. RR 40/min

What do people think?

The important thing to say at outset is that this is a sick baby. The more rapid and sudden the outset of illness, the potentially sicker the baby is. So some comments about the vitals:

1. PR 234 bpm (really tachycardic- for anyone)
2. T 38° febrile
3. RR within range

So what are some normal figures? I’ve shared the way I calculate weight before. The way I remember is this.

1. 1yr – 10kg
2. 3yr – 15kg
3. 5yr – 20kg
4. 7yr – 25kg
5. 9yr – 30kg

What about smaller children?

1. Birth – 3.5kg
2. 6month – 8kg

If you remembered 3.5, 7, 10, 15, 20, 25, 30, you would be okay.

What about pulse rate?

Well, 234bpm is high for anyone.

I remember that children from:

Birth to 1 year – 170bpm

0-1 year – 170bpm

1 year – 170bpm

3 years – 150bpm

5 years – 130bpm

7 years – 110bpm

9 years – 110bpm

Can you see the pattern? Reducing by 20 every time until 9.

Now there are ways you can get all these values. They may be on your computer, or a ‘tape’ or somewhere you personally keep this data, like an organiser. The reason I teach the simple ways to remember things is that you may not always be at the hospital you know, you may be in another hospital, where you can’t get rapid access to this material.

Respiratory rate is within normal limits.

We were not able to get a BP – this at the time was probably a mechanical issue.

What other readings are important here?

1. Take a BSL (it was 5.1).

2. The other thing to do is capillary refill.

The other thing we need to beware of is that the tachycardia is not SVT.  The ECG demonstrated a regular marrow complex tachycardia with P waves – so this was a sinus tachycardia.

So how did we approach this child?

The baby was already in a resus cubicle with monitoring attached.

We checked:

Airway – the baby was crying which indicated an intact airway. There was no stridor or other sound.

Breathing – there was good air entry, no tachypnoea and the sats were 98% on room air.

Circulation – this is the critical part here. The baby was tachycardic which was a response attempting to maintain cardiac output. Remember and beware of bradycardia as this may also occur and is a potentially critical sign such that it may precede asystole.

BP is good to take, however hypotension is a late sign and the child may be normotensive and in trouble.

Capillary refill is a useful sign – press for about 5 seconds and let go. Can use the finger, or can use the area around the wrist.

* Refill < 2 sec = normal
* Refill 2-4 sec = delayed and means a fluid deficit


Next we need to assess the child in terms of neurological states, and we can use the AVPU formula.

* Awake
Verbal response
Pain response

This baby was awake.


This baby had a minor blanching rash on the right foot and nil else.

ENT examination was normal.

As we look at the ABC I remember also being taught DEFG: “Don’t Ever Forget Glucose”.

If the glucose is low, we give 5ml/kg of 10% dextrose.

So how did we manage this baby?

We recognised early that this was a sick septic baby with potential shock. It is important in septic shock to treat the infection as a matter of urgency.

* We had established airway and breathing were okay.
* We established IV access – we got this on first attempt. If we didn’t get it on first attempt, we would try one more time then
intraosseous would be attempted.

A word on intraosseous:

* What types are there? There is the cannula type with stylette and there is the drill-type.
* Where do we insert? Medial to proximal tibia about 1cm below tibial tuberosity to miss the epiphysis (can use distal femur).

When you aspirate, you get marrow. Remember that in children older than 5yo, the marrow becomes fatty and aspiration may not be possible.

There are the expected potential complications

* trauma (may penetrate posterior cortex, multiple attempts can result in extravasation)
* infective – cellulitis, osteomyelitis
* can also get compartment syndrome

Take bloods when IV in: need FBC, EUC, venous gases, lactate, blood cultures.

Give fluid as bolus – if child is obtunded, 20ml/kg N saline.

We give 2x 10ml/kg bolus (why? I don’t know) to this child as he was not totally obtunded.

While this was being done, we took a urine specimen by catheter.

This was positive for leukocytes (it lit up).

We gave antibiotics – cefotaxine 50mg/kg and we added gentamicin 7mg/kg. With the antibiotics etc, the baby had a total input of about 30ml/kg of fluid.

We consulted with paediatrics early and the paediatric consultant also agreed with our management.

At all times we kept mum, dad and grandma there and informed. At every step we spoke to them about what we were doing and what to expect. We also explained why we were doing what we were; why the antibiotics were being given etc (take note Fellowship candidates).

Over the next 30mins:

– the heart rate decreased
– the baby settled and was more alert. Soon after this he was interacting, smiling and playing

This was a very quick recovery, but you sometimes see that. Bloods showed mild acid base imbalance and increased WCC

The point is – get antibiotics and fluids in quickly in a flat baby.

Somebody asked the question – would you lumbar puncture?

My answer was NO for two reasons:

1. We found infection in urine
2. LP may not be the best investigation if there is any question of altered level of consciousness, prior to excluding space occupying lesion.


  • admin says:

    Adrian Bonsall emailed with some great comments. The most important ones were:
    “Why give half measures? ” in reference to the fluids- Quite right- and the truth is…….I don’t know. In fact the child got 10ml/kg and then 10ml/kg right after each other- so really 20, but I gotta write it as I do it!
    Another comment was:
    “Although you can take a CRT peripherally, if it is prolonged (>2s) then you should check it (or ideally take it in the first place) over the sternum or forehead as the peripheral circulation may be reduced by ambient conditions or a fever in children and give you an inaccurate response.”
    “I don‚Äö√Ñ√¥t think this child required a LP, but don‚Äö√Ñ√¥t be too quick to discount the possibility of meningitis. The presumed UTI in this child based (on what we‚Äö√Ñ√¥ve been told) on leucocytes in the urine is not by any means conclusive. WBC is common in many febrile illnesses in children, and UTIs can happily co-exist with a number of other infections, especially in young infants.
    The risk of LP in this case where the child was far from moribund was probably negligible and not a reason to defer.”

    Goods comments and thanks for taking the time to give feedback.

  • John Mackenzie says:

    A good case for discussion. My additional comments …

    Clinical observations:
    Initial pyrexia may be followed by falling temperature and hypothermia in severe/ worsening sepsis.

    Septic work-up:
    Blood cultures etc, I normally take by brachial artery puncture overlying the medial epicondyle. (IV catheter aspiration more likely to be contaminated).
    Urine specimen – if a voided specimen not possible, then suprapubic aspirate (SPA) is de rigeur.
    Lumbar puncture – I would do in infant with septic shock. It’s the quickest (1 min) and easiest procedure to do on neonates and infants. Just flex the back (by assistant), and 23g x30mm (blue) needle inserted perpendicular in midline at the level of the iliac crests – few drops CSF into 2 sterile tubes.

    20 ml/kg saline bolus, repeated if poor circulatory response.
    If still poor circulatory response, then needs inotrope – noradrenaline is the ideal, but needs to be given via CVC. IM adrenaline is the practical alternative an the emergency.
    Oxygen (don’t forget).

    Agree, Cef Genta if urine pos for leuk’s nitrite G -ve bacilli on micro.
    But if urine neg (or just pos for leuk’s) then I would like to give IV PenG (usually best for streps, pneumococci, menigococci) Genta (best for G -ves) Cef (2nd best for streps and G -ves, but gives additional cover and spectrum, to be sure, to be sure).

    Follow up:
    If final diagnosis severe UTI, then renal US scan is the minimum follow up.

    – John Mackenzie (Monash ’74, and neonatal s/reg Mercy Melbourne ’86/87/88)

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