What would you do?

[Stitch]

So I wanted to present this case and see how people respond. I've changed a few things to obscure anything too identifying. In general we as pediatricians often don't do as well with adolescents. Everyone is welcome to join in (med students, residents, any NPs around).

16 year old male comes in complaining of rash and facial swelling. He's been feeling just 'blah' for the past week or so. Was seen last week for the same, and 'some tests were done,' but he's not getting any better.

What do you want to know?

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[aliendancer84]

When you say rash and facial swelling, what do you mean? Does he have a petechial/purpura rash and periorbital swelling? Does he have parotid swelling and a viral exanthem? Does he have a maculopapular rash and swollen cervical lymph nodes? Etc...

Any other symptoms? Vaccines UTD? Anyone at home sick? What tests were done? PMH?

 

[Pembleton]

Is he sexually active?

 

[smq123]

16 year old male comes in complaining of rash and facial swelling. He's been feeling just 'blah' for the past week or so. Was seen last week for the same, and 'some tests were done,' but he's not getting any better.

* Where is the rash? Does it itch?

* What part of his face is swollen? What makes him think that it is swollen?

* Any fevers, myalgias, etc?

* What tests were done?

 

[NOsquid]

Are we zebra hunting?

Travel history? Family history? Meds? HIV?

 

[Lizzy Wurtzel]

Are we zebra hunting?

Travel history? Family history? Meds? HIV?

He won't admit it, but I bet he abuses ACE inhibitors. Urine tox screen?

 

[nighttrain]

human with rash. DISCUSS!

 

[Stitch]

Sorry guys, long day at work. I'll throw some more info out. And I don't actually think this is a zebra, but it poses some management questions.

PMH: generally healthy, but does have migraines. He was started on tegretol a couple of months ago.

He denies sexual activity. I believed him. Boys brag about it, girls hide it.

Luckily he brought a print out of his previous tests.
CBC at the time showed:
WBC 2.8, 30% bands and 10% eos,platelets 116

repeated 2 days later (by PCP)
CBC WBC 3.9, 55segs, 33 lymphs, 4 monos, 5 eos
ESR 27, CRP 2.3

Initially (when these labs were drawn) the rash was more papular on an erythematous base covering his trunk and some of his arms. Not sandpaper like. He had some 'low grade' temps and malaise, but no muscle pain or true myalgias. At presentation today, the rash has changed to a more confluent pink/red and moved up to his face. I'll give more, along with vitals at the next post or so.

 

[J-Rad]

Stop the Tegretol.
Also check if/how the mucous membranes and conjuctiva are affected by the rash.
He is a migraneur-did he not tell you that he's been taking ibuprofen for his headaches in the last few weeks? Was he given any medications after the labs showing low WBC and a bandemia?
Has he had a rash/clinical presentation like this before?

Other labs:
Complete metabolic panel
ANA, complement, anti-Sm antibodies, and what was the H&H (?)

Immediate concern: Is this Stevens-Johnson/TENS (thus the questions about other drugs. Unusual to be present >a 2-3 weeks past initiation of drug). Overall, story as presented, barring other features, doesn't sound too much like it, but should be on the DDx. Carbamazepine is the #1 drug to cause it. I wouldn't hesitate to call my local derm peeps and run it by them after collecting more data.

Less emergent concern: is this drug induced lupus or systemic lupus erythematosus (the differentiation will come later, but some of the labs may help as would clinical course after stopping med).

But more pressing concern if yes: organ damage, particularly lupus nephritis a/o hepatic involvement.

There are two+ cell lines down which always makes me nervous for malignancy, however the rash as described would seem to lead in another direction (I don't ever recall of leukemia presenting with this type of rash) and lupus can cause cytopenias. But for thoroughness sake, I want to know if the differentials described were manual or automated-only. I trust well trained eyes more and blasts can get reported as bands on an automated diff IIRC.

First thoughts.

 

[J-Rad]

PS, thanks for posting a case. I've been missing these.

 

[J-Rad]

Hate the show, love the meme-it's gotta go in:

 

[legobikes]

Stop the Tegretol.

There are two+ cell lines down which always makes me nervous for malignancy, however the rash as described would seem to lead in another direction (I don't ever recall of leukemia presenting with this type of rash) and lupus can cause cytopenias. But for thoroughness sake, I want to know if the differentials described were manual or automated-only. I trust well trained eyes more and blasts can get reported as bands on an automated diff IIRC.

First thoughts.

yeah and pretty sure m fungoides doesn't progress this quickly.

 

[Stitch]

Excellent thoughts! The differential was auto, which I'm told also spits out a lot of eos. H/H were 13/39.

Here is the physical exam and vitals at the time of presentation to the ED (about a week after the second CBC was done). He has remained on the tegretol, and the PCP's plan was to recheck everything in a week. They came to the ED because he feels worse.
T 38.3, Pulse 113, RR 20, BP 123/64, PO2 96% (RA), Wt 54 kg

Generally well-appearing, interactive in no apparent distress.
Erythematous rash diffusely on the upper trunk and face. (mom notes it looks as if he's been out in the sun) No areas of excoriation. Face appears very slightly puffy, as do his hands. No skin peeling.
Mild non tender lymph adenopathy in the cervical area, nowhere else
No oral lesions, and no conjunctivitis
CTAB
RRR no m/r/g, brisk cap refill.
Abd st/nt/nd, no hsm, no flank tenderness

 

[J-Rad]

Recheck a manual BP, DynaMaps often overestimate diastolic hypotension (they oversense the change in Karatkoff sounds at a lower level as compared to the human ear). It's not true D-hypotension at the number you reported, but it may be spuriously giving you the impression of a widened pulse pressure.

He is a little tachycardic, but not out of proportion to his temp. I might be tempted to give an antipyretic and assess for improvement, but not knowing if he has hepatic involvement or worsening thrombocytopenia (you didn't give a repeat PLT count), I might hold off until more data is available.

Kid's febrile, tachycardic with abnormal CBC, ESR, CRP. Antibiotics? Dunno. He's looks good, you seem to have a little time on that decision though there may not be a right answer to that one.

Add a monospot to the lab panel. Can you get a CMV back in a reasonable amount of time?

 

[Stitch]

Recheck a manual BP, DynaMaps often overestimate diastolic hypotension (they oversense the change in Karatkoff sounds at a lower level as compared to the human ear). It's not true D-hypotension at the number you reported, but it may be spuriously giving you the impression of a widened pulse pressure.

Kid's febrile, tachycardic with abnormal CBC, ESR, CRP. Antibiotics? Dunno. He's looks good, you seem to have a little time on that decision though there may not be a right answer to that one.

Add a monospot to the lab panel. Can you get a CMV back in a reasonable amount of time?

CMV takes days to come back, so not very helpful to us in the ED. Good thought, however! Here's most of what else you suggested though. Now what? How concerned are we?

CMP wnl except Ca 8.7, AST/ALT 173/389, alk phos 300
CBC: WBC 9.7, H/H 12/37, plt 234
60s, 7bands, 17L, 6mono, 5eo, 5atyp lymph
Mono neg, rapid strep neg
CRP 2.5
UA nitrate neg, le trace, many bact, many squamous, 2-5 wbc, 3-5 rbc, sl cloudy, >80 ketones

 

[J-Rad]

Get a little further history on fever and rash: have the fevers been all day or do they tend to have a twice-daily spike? How long has he actually been having fevers? Is the rash consistent or does it come and go, and if the latter, does a warm shower bring it out? So far the story doesn't scream systemic onset JIA but it wouldn't be good to miss this with a milder presentation of MAS (which I don't think this is-just exploring more the zebra-ish end of things). Any unusual bowel history (diarrhea, bloody stools)?

Truth be told, at this point, this gets outside of what I'd want to actively manage in the ED or even as a PCP. There's enough to lead me in a rheumatological direction, though this may be an initial double consult with GI. Still have drug induced or systemic lupus on list. Also autoimmune hepatitis. Get a +/- on ibuprofen to make him feel better and a +/- on go home with next day f/u with rheum and/or GI (I realize that I'm ignoring the abnormal UA for now, but with other issues going on I don't necessarily know of what significance it is. Does he have a nephritis? Maybe. Does he have a UTI? A cognitively intact 16yo with a UTI and no dysuria-doesn't seem likely. Does he GC (despite his denials of sexual activity) and this is Fitz-Hugh-Curtis? Well he's really the wrong gender for that (and rash isn't usually a part) but it's been described in males on rare occasion. OK, let's back out of that rabbit hole) or admission given undifferentiated etiology and hepatidity.

And I'm sending a rotten egg to your work if you take this long next time. I can only deal with so many WAMC and what should I do threads

 

[Stitch]

And I'm sending a rotten egg to your work if you take this long next time. I can only deal with so many WAMC and what should I do threads

The way work has been going lately, that might be an improvement!

I keep hoping some med studs or residents will join in here, hence the long delays. What happened to everyone??

More soon, I promise.

 

[J-Rad]

I tried to be patient and keep my keys quiet

 

[Stitch]

Wow, okay, moving on.

My main focus is 'sick' or 'not sick.' This guy doesn't look or act sick, and all his repeat labs aren't too concerning. If anything they look better. I will say that anyone with a sunburn looking rash gets my attention, which is part of why I did the work up. I was thinking CMV/EBV or some sort of vasculitis such as lupus.

Reassessment:
Temp 38, pulse 119, RR 22, BP 97/52, sats 100%

He says he feels a little light headed, and a little nauseated.

Now what do you think?

 

[fleetgoddess]

-I'm thinking rheum. This somewhat reminds me of a lupus patient I had and the UA could go along with renal involvement. I'm not sure if there is any overlap with autoimmune hepatitis but I guess a lot of rheum overlaps.

-Initially with the rash and fever I was thinking more viral or even a strep rash but not really thinking that anymore.

-The nausea, headache, rash, LFTs, etc could also be erlichia.

-primary hiv infection

I may come back and actually read the whole thing without skimming parts at 3 am and maybe come up with something else.

Thanks

 

[Marcus Brody]

secondary syphilis

 

[smq123]

Excellent thoughts! The differential was auto, which I'm told also spits out a lot of eos. H/H were 13/39.

Here is the physical exam and vitals at the time of presentation to the ED (about a week after the second CBC was done). He has remained on the tegretol, and the PCP's plan was to recheck everything in a week. They came to the ED because he feels worse.
T 38.3, Pulse 113, RR 20, BP 123/64, PO2 96% (RA), Wt 54 kg

Generally well-appearing, interactive in no apparent distress.
Erythematous rash diffusely on the upper trunk and face. (mom notes it looks as if he's been out in the sun) No areas of excoriation. Face appears very slightly puffy, as do his hands. No skin peeling.
Mild non tender lymph adenopathy in the cervical area, nowhere else
No oral lesions, and no conjunctivitis
CTAB
RRR no m/r/g, brisk cap refill.
Abd st/nt/nd, no hsm, no flank tenderness

Not complaining of any joint pain? No myalgias?

With the face and hand swelling, my first thought was autoimmune, but now parvovirus also comes to mind.

Wow, okay, moving on.

My main focus is 'sick' or 'not sick.' This guy doesn't look or act sick, and all his repeat labs aren't too concerning. If anything they look better. I will say that anyone with a sunburn looking rash gets my attention, which is part of why I did the work up. I was thinking CMV/EBV or some sort of vasculitis such as lupus.

Reassessment:
Temp 38, pulse 119, RR 22, BP 97/52, sats 100%

He says he feels a little light headed, and a little nauseated.

Now what do you think?

Is he keeping fluids down? Staying well hydrated? I'd treat his light-headedness and nausea with some rehydration first (do the simple basic stuff), and see if it helps.

 

[Stitch]

Not complaining of any joint pain? No myalgias?

With the face and hand swelling, my first thought was autoimmune, but now parvovirus also comes to mind.

Also a good thought. No joint pains.

-I'm thinking rheum. This somewhat reminds me of a lupus patient I had and the UA could go along with renal involvement. I'm not sure if there is any overlap with autoimmune hepatitis but I guess a lot of rheum overlaps.

-Initially with the rash and fever I was thinking more viral or even a strep rash but not really thinking that anymore.

-The nausea, headache, rash, LFTs, etc could also be erlichia.

-primary hiv infection

Reassessment:
Temp 38, pulse 119, RR 22, BP 97/52, sats 100%

He says he feels a little light headed, and a little nauseated.

Look at these vitals again and see if anything jumps out here. The BP was repeated manually. Why do we think he's now light headed and nauseated?

Is he keeping fluids down? Staying well hydrated? I'd treat his light-headedness and nausea with some rehydration first (do the simple basic stuff), and see if it helps.

Fluids have been staying down, but he admits not to drinking as much as usual. Rehydration is a good idea. How would you implement it?

 

[SurfingDoctor]

Uncompensated shock = hospital, fast

I never saw a travel history, time of year or exposure to tick-borne pathogens.

 

[BigRedBeta]

Fluids have been staying down, but he admits not to drinking as much as usual. Rehydration is a good idea. How would you implement it?

Fever, Tachycardia, Tachypnea...without having ruled out infectious cause.

Sepsis, sepsis, sepsis, sepsis...<wait for it> SEPSIS.

I always keep myocarditis in the back of my mind (more so since I just came off of cards), but one 20ml/kg bolus in this kid who has a week of feeling "blah" is probably in need of being tanked up is appropriate. Certainly, this is not time where I write for the bolus and go grab lunch. At a minimum I'm nearby, if not bedside to see how his HR responds. Would also be ordering a chest x-ray, which may make me feel better one way or the other.

 

[Stitch]

Uncompensated shock = hospital, fast

I never saw a travel history, time of year or exposure to tick-borne pathogens.

Winter. No tick exposure and no recent travel.

Fever, Tachycardia, Tachypnea...without having ruled out infectious cause.

Sepsis, sepsis, sepsis, sepsis...<wait for it> SEPSIS.

I always keep myocarditis in the back of my mind (more so since I just came off of cards), but one 20ml/kg bolus in this kid who has a week of feeling "blah" is probably in need of being tanked up is appropriate. Certainly, this is not time where I write for the bolus and go grab lunch. At a minimum I'm nearby, if not bedside to see how his HR responds. Would also be ordering a chest x-ray, which may make me feel better one way or the other.

Now we're getting somewhere. Myocarditis is always good to think about because it looks like everything else. Still, with the falling blood pressure (repeat is now 92/53), this kid needs fluid. Exam now shows a 3-4 second cap refill, but liver isn't down, and there aren't any murmurs or gallops.

I think shock is something we as peds people either don't recognize quickly enough or don't treat aggressively enough. So fluid is a great idea. How much and over how much time? The nurse gets ready to run a liter over an hour.

 

[SurfingDoctor]

Hard and fast...

http://www.nejm.org/doi/full/10.1056/NEJMoa010307

Mom says it looks like he's "been in the sun" during winter? Is that because of the rash or is he more "tan" that other people around him?

 

[Stitch]

Hard and fast...

http://www.nejm.org/doi/full/10.1056/NEJMoa010307

Mom says it looks like he's "been in the sun" during winter? Is that because of the rash or is he more "tan" that other people around him?

Not tan, but red, like a sunburn.

 

[BigRedBeta]

Winter. No tick exposure and no recent travel.



Now we're getting somewhere. Myocarditis is always good to think about because it looks like everything else. Still, with the falling blood pressure (repeat is now 92/53), this kid needs fluid. Exam now shows a 3-4 second cap refill, but liver isn't down, and there aren't any murmurs or gallops.

I think shock is something we as peds people either don't recognize quickly enough or don't treat aggressively enough. So fluid is a great idea. How much and over how much time? The nurse gets ready to run a liter over an hour.

And I'm pulling out the rapid infuser...


I agree, peds people really do struggle with sepsis and shock. It's something that repeatedly shows up at our M&M conferences. It's something that even the best children's hospitals struggle with (see Texas Children's ER QI project that was published in last month's Pediatrics).


With that physical exam, I'm looking for 60ml/kg in 15 minutes as my target, and with a falling BP, I'm probably putting the order in for dopamine drip to be at the bedside in case he doesn't respond to fluids.

Is he still talking to us? What about his legs - are they cold? How far up until you get "warm" skin?

I'm also thinking now is the time for antibiotics. Any reason why we need an LP before that?

 

[SurfingDoctor]

^Remember, you can be warm and well perfused on exam and still be in shock... mental status is a great marker though as well as urine output.

So, blanching rash with malaise, FUO that progresses to shock...

Infectious etiology would still be high on my list, blood cx, ECHO, viral cx, some vector-borne pathogen.

Maybe I wasn't fully paying attention but lupus or an autoimmune process would still be high. Something rare like HLH or dysautonomia would be on the list but lower.

Honestly, I'd phone a friend... FUOs are not my specialty.

 

[Stitch]

And I'm pulling out the rapid infuser..

With that physical exam, I'm looking for 60ml/kg in 15 minutes as my target, and with a falling BP, I'm probably putting the order in for dopamine drip to be at the bedside in case he doesn't respond to fluids.

Is he still talking to us? What about his legs - are they cold? How far up until you get "warm" skin?

I'm also thinking now is the time for antibiotics. Any reason why we need an LP before that?

Exactly. Rapid. I remember as a resident getting a ton of pushback, usually from nursing, about how fast we can give fluid. 'The pump only runs at 999/hr!' or 'I'm not comfortable running that much fluid.'

You have to be willing to stand your ground and stay at the bedside. I put in a second IV and had the resident and the nurse also at the bedside pushing NS through a large syringe at the same time. I'll post the next hour's worth of BPs shortly, but suffice it to say, I put 4 liters into this kid in under an hour, 4x times what he would have gotten at 999/hr.

Keep checking for a falling liver or a gallop (none noted).

Yes, he's still talking, he just feels worse. Extremities somewhat cool, cap refill closer to 4 seconds, warm a little below the ankle.

Which antibiotics and why?

^Remember, you can be warm and well perfused on exam and still be in shock... mental status is a great marker though as well as urine output.

So, blanching rash with malaise, FUO that progresses to shock...

Infectious etiology would still be high on my list, blood cx, ECHO, viral cx, some vector-borne pathogen.

Maybe I wasn't fully paying attention but lupus or an autoimmune process would still be high. Something rare like HLH or dysautonomia would be on the list but lower.

Honestly, I'd phone a friend... FUOs are not my specialty.

I grabbed a blood culture and sent off a rapid flu. It's pending.
Chest x ray (portable! death begins in radiology!) is essentially unremarkable. No infiltrates and the heart doesn't appear huge.

 

[BigRedBeta]

, I put 4 liters into this kid in under an hour,

Yes, he's still talking, he just feels worse. Extremities somewhat cool, cap refill closer to 4 seconds, warm a little below the ankle.

Which antibiotics and why?

Well, I'd like to see the BP's, but hopefully that dopamine infusion I ordered as made it's way from the pharmacy to the ED. After 4 liters, I'm also thinking about making my next bolus 5% albumin.

Honestly, I'm pretty weak with any of the rheum stuff, so infection is front and center on my differential - with the progression of symptoms at least seeming to fit a bacterial superinfection type picture, but that doesn't mean there aren't other things that can cause a SIRS response and development of shock. I feel a bit more reassured that I can lower myocarditis on the differential with the CXR not throwing up any red flags and him tolerating aggressive fluid resuscitation.

While contemplating antibiotics, if this really is infectious, I'm a little thrown off by the lack of focus to this infection. Elevated liver enzymes, rash...I just don't have a lot to go on. I think I'm going to try to cover for everything going with something like zosyn and vanc at least to start out on.

How do our vital signs (and our patient) look?

 

[Stitch]

Well, I'd like to see the BP's, but hopefully that dopamine infusion I ordered as made it's way from the pharmacy to the ED. After 4 liters, I'm also thinking about making my next bolus 5% albumin.

Honestly, I'm pretty weak with any of the rheum stuff, so infection is front and center on my differential - with the progression of symptoms at least seeming to fit a bacterial superinfection type picture, but that doesn't mean there aren't other things that can cause a SIRS response and development of shock. I feel a bit more reassured that I can lower myocarditis on the differential with the CXR not throwing up any red flags and him tolerating aggressive fluid resuscitation.

While contemplating antibiotics, if this really is infectious, I'm a little thrown off by the lack of focus to this infection. Elevated liver enzymes, rash...I just don't have a lot to go on. I think I'm going to try to cover for everything going with something like zosyn and vanc at least to start out on.

How do our vital signs (and our patient) look?

Here are the sequential BPs:

1400: P 113, BP 123/64
1535: P 119, BP 97/52
1600: P120, BP 92/50
1608: P118, BP 100/43
1700: P118, BP 105/46
1715: P125, BP 75/51
1730: BP 59/37

Dopamine was in fact started towards the beginning of the third bolus, and you can see the bump in BP. I wonder now if norepi would have been a better choice given the clinical picture. Any thoughts on that?

As for antibiotics we went with vanc and clindamycin. My concern was what you mentioned: a lack of focus. To me, the fever, malaise and rash signaled a vasculitis of some sort, either rheum or toxin mediated. If he were a she, I would probably have been asking about tampon use. As I said, I'm generally scared of sunburn rashes.

Reassessment: feeling worse and worse. Liver still not down, no gallops, no edema. No crackles either.

At 1730 he's still arousable, but becoming obtunded and confused. Now what?

 

[J-Rad]

I trained in a program that had no particular love of DA. The way that I would have gone (not saying mine was the right or wrong way, rather the one I was trained in) would be Norepi for warm shock (warm extremities and flash cap refill) or Epi for cold shock (cool extremities and delayed CR, which is what he seems to be evolving to).

http://www.pediatricer.com/septic_shock0001.pdf
Here's the 2006 Guidelines for septic shock. Word bolded because they are just that-guidelines, not biblical tenets.
Here's my thoughts: as soon as he was declaring fluid refractory hypotension requiring vasopressors, he bought himself a CVL, art line, and intubation. His MS deterioration further confirms the need for it. RSI, tube, and line. Hopefully he is in the unit by now. Not in the guidelines above, but I would think of adding phenylepherine gtt to the mix in the setting of consistent diastolic hypotension. Titrate for better perfusion picture and SVO2s and then pick some numbers that work. If CVPs not getting overly high/liver not down, consider continued fluid bolusing until better perfusion. Rainbow labs. If HCT remotely low (<40) transfuse. If albumin <2.2 tranfuse albumin. If coagulopathic, treat accordingly. Baseline ABG after intubation for vent management and another piece of clinical picture. If spot cortisol normal or low, hydrocortisone. Stat ID and Rheum consults.

 

[BigRedBeta]

J.Rad beat me to it...


More pressors. More fluid. A central line. An art line. Help from the PICU.

At this point, a head CT and an LP are on my wish list, but he's not stable enough for either one. I can do without at the moment.

An echo would be appreciated as well.

With his change in mental status, how obtunded are we talking? What's his GCS? You haven't mentioned respirations, sats, etc but I'm going to keep reevaluating the need to intubate through all this as well.

If it hasn't been done, by this point, a foley would be helpful. And if we're adding tubes, an NG.

 

[J-Rad]

J.Rad beat me to it...


More pressors. More fluid. A central line. An art line. Help from the PICU.

At this point, a head CT and an LP are on my wish list, but he's not stable enough for either one. I can do without at the moment.

An echo would be appreciated as well.

With his change in mental status, how obtunded are we talking? What's his GCS? You haven't mentioned respirations, sats, etc but I'm going to keep reevaluating the need to intubate through all this as well.

If it hasn't been done, by this point, a foley would be helpful. And if we're adding tubes, an NG.

This is going to sound overly opinionated and gruff, so apologies ahead of time. One advantage of going through these cases in this forum is that you get to try to sound like you would have had the perfect answer at the time in the middle of chaos...

Foley: Outstanding idea. The best of them. Poor man's Swan.

Head CT: seemed to have had a non-focal exam and his picture of septic shock would seem to explain his AMS, so I'm not sure it adds anything.

LP: Would it change anything? He's committed to big gun abx for as long as infection remains on the DDx. As stated, he isn't in any shape for either test yet.

Echo: I would argue that this is a useless study right now. Liver isn't down, no gallop, and if he's making urine, he's got cardiac output. So he has normal or hypercontractile LV function. Are you going to stop your therapies with that data point? Alternatively, he develops hepatomegaly and a gallop-are you going to wait for your call-in echo to make a change in your management? If you make the appropriate therapeutic intervention and there is clinical imporvement, what has your echo added to the story? It's a bit of a bugaboo that the echo is looked at as such a reassuring test, but often your clinical exam/status is much more useful. This is a study that can wait.

Lastly, I don't think his GCS matters one whit. He's septic with fluid and pressor refractory hypotension. He has AMS. 20/20 hindsight says he probably should have been tubed earlier, but if he was cogent and resistant (i.e. couldn't be convinced that he was about to crash and needed it) this may have been a medicolegal nogo. At this point he gets a tube.

 

[Stitch]

I trained in a program that had no particular love of DA. The way that I would have gone (not saying mine was the right or wrong way, rather the one I was trained in) would be Norepi for warm shock (warm extremities and flash cap refill) or Epi for cold shock (cool extremities and delayed CR, which is what he seems to be evolving to).

I was actually worried about epi worsening the diastolic dysfunction give the beta receptor action. But then, I don't use these drugs that often, and I'm sure there's a couple different ways to approach it.

 

[Stitch]

J.Rad beat me to it...


More pressors. More fluid. A central line. An art line. Help from the PICU.

At this point, a head CT and an LP are on my wish list, but he's not stable enough for either one. I can do without at the moment.

An echo would be appreciated as well.

With his change in mental status, how obtunded are we talking? What's his GCS? You haven't mentioned respirations, sats, etc but I'm going to keep reevaluating the need to intubate through all this as well.

If it hasn't been done, by this point, a foley would be helpful. And if we're adding tubes, an NG.

Great idea on the foley. Didn't think of it at the time, but definitely worth it.

What were you looking for with the LP/CT? Meningitis? Just curious.

Foley: Outstanding idea. The best of them. Poor man's Swan.


Echo: I would argue that this is a useless study right now. Liver isn't down, no gallop, and if he's making urine, he's got cardiac output. So he has normal or hypercontractile LV function. Are you going to stop your therapies with that data point? Alternatively, he develops hepatomegaly and a gallop-are you going to wait for your call-in echo to make a change in your management? If you make the appropriate therapeutic intervention and there is clinical imporvement, what has your echo added to the story? It's a bit of a bugaboo that the echo is looked at as such a reassuring test, but often your clinical exam/status is much more useful. This is a study that can wait.

Lastly, I don't think his GCS matters one whit. He's septic with fluid and pressor refractory hypotension. He has AMS. 20/20 hindsight says he probably should have been tubed earlier, but if he was cogent and resistant (i.e. couldn't be convinced that he was about to crash and needed it) this may have been a medicolegal nogo. At this point he gets a tube.

As for the echo, at the time we figured that if he could take 4 liters of fluid without signs of failure then cards wasn't likely to get interested. We have a hard enough time getting them involved when it IS the heart.

Remember that GCS is an acute assessment specifically designed for a trauma patient, especially in the field. We use it for other things, but just be aware on how and why you use it ( though I realize you were asking more for clarification/quantification of this guy's mental status).

Expected or concerning clinical course is a reasonable justification for intubation, so at the 1715 mark, I was pulling out the airway box, and readying some RSI drugs. He got tubed after the 1730 pressure. Given our clinical concern for sepsis, and toxic shock type stuff, what drugs would you use or not use?

 

[J-Rad]

As for the echo, at the time we figured that if he could take 4 liters of fluid without signs of failure then cards wasn't likely to get interested. We have a hard enough time getting them involved when it IS the heart.

It's not the heart

 

[BigRedBeta]

As for the LP/CT...I'll freely admit that this is my inexperience. The only patient I've taken care of directly who decompensated in front of my eyes like this ended up with paraspinal abscesses that eventually extended into his spinal column (which we could see on ultrasound) and by the time we got a CT (when stable) pus was into his 4th ventricle. I realize that this was a rare case/complication and am overreacting to the bad outcome.

The GCS...it's hard to get an understanding of what this kid looks like with just "obtunded and confused", which is why I asked.

For RSI in septic shock - leave the etomidate in the box.

 

[KidDr]

Great idea on the foley. Didn't think of it at the time, but definitely worth it.

What were you looking for with the LP/CT? Meningitis? Just curious.




As for the echo, at the time we figured that if he could take 4 liters of fluid without signs of failure then cards wasn't likely to get interested. We have a hard enough time getting them involved when it IS the heart.

Remember that GCS is an acute assessment specifically designed for a trauma patient, especially in the field. We use it for other things, but just be aware on how and why you use it ( though I realize you were asking more for clarification/quantification of this guy's mental status).

Expected or concerning clinical course is a reasonable justification for intubation, so at the 1715 mark, I was pulling out the airway box, and readying some RSI drugs. He got tubed after the 1730 pressure. Given our clinical concern for sepsis, and toxic shock type stuff, what drugs would you use or not use?

Great case.
I would probably intubate this guy with Ketamine and Rocuronium. And I would ask a colleague to put in an IO once the Ketamine was in (or do it myself after the intubation), and start Norepi. Just out of curiosity, how much Dopamine was he on at this point? (when BPs were dropping). I would be considering giving steroids, and I would be thinking about what I would use as a 3rd pressor as well (and hoping the kid would be in the PICU before I had to use it). And I would give a dose of Zosyn or something else with good gram negative coverage.

 

[SurfingDoctor]

Maybe I missed it, but I didn't see anything about the capillary refill and skin temperature with those BPs and after interventions. Really, that with a mixed venous saturation should be what determines your vasoactive agent. You may start one agent and the exam could change for which you should alter you therapies.

If he's really maxed on two vasoactive agents, I would give him stress dose steroids. Since he been sick for a while with weird symptoms and then got sick really quickly, I would give Doxycycline for antimircobial therapies as well.

And just because I have to ask, did he happen to have a pulse with the blood pressure of 59/37? You didn't give a heart rate and he is probably having profound myocardial dysfunction with that BP.

 

[SurfingDoctor]

Since this is also a real case (right?), how did that intubation go with a BP of 59/37? That would have my (insert orifice) tighten to maximum. Seen a couple of hypotension intubations cause arrest, especially with hypovolemic or distributive shock. Gotta make sure you got your hand on volume/epi button.

 

[Stitch]

Maybe I missed it, but I didn't see anything about the capillary refill and skin temperature with those BPs and after interventions. Really, that with a mixed venous saturation should be what determines your vasoactive agent. You may start one agent and the exam could change for which you should alter you therapies.

If he's really maxed on two vasoactive agents, I would give him stress dose steroids. Since he been sick for a while with weird symptoms and then got sick really quickly, I would give Doxycycline for antimircobial therapies as well.

And just because I have to ask, did he happen to have a pulse with the blood pressure of 59/37? You didn't give a heart rate and he is probably having profound myocardial dysfunction with that BP.

Sorry, I didn't put enough info there. He was still tachycardic (like 150s), but I don't remember the actual number. Cap refill was getting towards 5 sec. Steroids are a great idea. I usually communicate with PICU when I'm adding a second pressor or thinking of steroids in order to get their input.

As for the LP/CT...I'll freely admit that this is my inexperience. The only patient I've taken care of directly who decompensated in front of my eyes like this ended up with paraspinal abscesses that eventually extended into his spinal column (which we could see on ultrasound) and by the time we got a CT (when stable) pus was into his 4th ventricle. I realize that this was a rare case/complication and am overreacting to the bad outcome.

For RSI in septic shock - leave the etomidate in the box.

Wow, that's a great case! Things like that always remind me to think outside of the box.

Etomidate: yes, leave it alone. We know it causes adrenal suppression, but people have pretty mixed feelings about its use in the ED. A number of studies have shown that it is correlated with increased mortality, but these were smaller studies. There's at least one decent study that says it might be ok, but this sepsis, hyptention-looking patient is exactly the patient who probably shouldn't get it. Anyone feel differently (I should look up those studies, but have baby in lap )

Great case.
I would probably intubate this guy with Ketamine and Rocuronium. And I would ask a colleague to put in an IO once the Ketamine was in (or do it myself after the intubation), and start Norepi. Just out of curiosity, how much Dopamine was he on at this point? (when BPs were dropping). I would be considering giving steroids, and I would be thinking about what I would use as a 3rd pressor as well (and hoping the kid would be in the PICU before I had to use it). And I would give a dose of Zosyn or something else with good gram negative coverage.

I started the Dopamine at 15, then bumped it up to 20. It didn't do much.

Since this is also a real case (right?), how did that intubation go with a BP of 59/37? That would have my (insert orifice) tighten to maximum. Seen a couple of hypotension intubations cause arrest, especially with hypovolemic or distributive shock. Gotta make sure you got your hand on volume/epi button.

Believe it or not, it was pretty smooth. We used ketamine and roc, as KidDr suggested, and his BPs greatly improved (I'll post them in a few minutes). I actually used a glidescope, got great visualization and an easy tube.

 

[Stitch]

1740: Ketamine & Rocuronium, P 136 BP 150/82
1800 BP >118/67

Patient was then transferred to the PICU where a central line was placed. We didn't do an IO in the ED because we had two 18 gauges in him already that had survived the initial fluid onslaught. Not that I ever mind breaking out the easy IO drill.

My final diagnosis leaving the ED was toxic shock syndrome. But it gets a little more interesting as we wait for cultures to come back.

 

[KidDr]

1740: Ketamine & Rocuronium, P 136 BP 150/82
1800 BP >118/67

Patient was then transferred to the PICU where a central line was placed. We didn't do an IO in the ED because we had two 18 gauges in him already that had survived the initial fluid onslaught. Not that I ever mind breaking out the easy IO drill.

My final diagnosis leaving the ED was toxic shock syndrome. But it gets a little more interesting as we wait for cultures to come back.

This is why I love Ketamine. It's almost like adding a 2nd pressor

Definitely agree that it makes sense to skip the IO in the ED if he's on his way up to the PICU to get a CVL, already has good PIV access, and his BPs have improved (even if only transiently).

Very curious to hear how this case turns out. Did he end up getting steroids? With his cap refill being so prolonged, I'm also curious to hear what pressor the PICU used in addition to dopamine (assuming that his BPs tanked again when the Ketamine wore off). I think when I posted above it didn't sound like it, but I'm with you in that I would getting the intensivist's opinion before starting a 2nd pressor.

 

[SurfingDoctor]

So BP >118/67 and cap refill of 5 secs and a wide pulse pressure? Again it all depends on exam, but to me that's low CO, high SVR ---> Milrinone or Dobutamine as long as systolics stay like that. If they drift down though, Epinephrine would be my choice. Low CO and high SVR is an usually presentation for TSS. They are usually high CO, low SVR. Did he every get an EKG?

What are his DIC panel, coags, H/H? Before this dude get lined up, I would have some products ready.

 

[Stitch]

So BP >118/67 and cap refill of 5 secs and a wide pulse pressure? Again it all depends on exam, but to me that's low CO, high SVR ---> Milrinone or Dobutamine as long as systolics stay like that. If they drift down though, Epinephrine would be my choice. Low CO and high SVR is an usually presentation for TSS. They are usually high CO, low SVR. Did he every get an EKG?

What are his DIC panel, coags, H/H? Before this dude get lined up, I would have some products ready.

Remember though that the BP you quoted was after the ketamine. Before that, it looked a lot like low SVR while being pretty tachy. H/H was normal, and he was off to the unit before the coags came back (but they were normal as well).

This is why I love Ketamine. It's almost like adding a 2nd pressor

Definitely agree that it makes sense to skip the IO in the ED if he's on his way up to the PICU to get a CVL, already has good PIV access, and his BPs have improved (even if only transiently).

Very curious to hear how this case turns out. Did he end up getting steroids? With his cap refill being so prolonged, I'm also curious to hear what pressor the PICU used in addition to dopamine (assuming that his BPs tanked again when the Ketamine wore off). I think when I posted above it didn't sound like it, but I'm with you in that I would getting the intensivist's opinion before starting a 2nd pressor.

We are using ketamine more and more for RSI, and I think that's a good thing. While one drug can never 'do it all,' ketamine is pretty versatile with a good safety profile.

Kid went to the unit. They stopped dopamine and left him on norepi for half a day or so when pressures stabilized. He spent three days on the vent, then was transferred to the floor where he stayed on the ID service for three more days or so.

Blood cultures were all negative. He was positive only for flu type B. So why did he crash? ID says that there are reports of TSS like syndrome associated with flu B, moreso than with flu A. There's also an association with staph infection that produces toxins (Thucydides syndrome?), however cultures were negative.

The neurologists mentioned that tegretol could also have been the culprit and that there are reported cases like this associated with the drug. The patient was discharged and told to stop the tegretol.

 

[SurfingDoctor]

Tegretol meaning the neurologist thought it was SJS/TEN as opposed to TSS?

Anyway, fun case to think through.