What symptoms are seen in meningitis in children?
95% of patients will have at least two of these four classic symptoms
Fever
Headache
Neck stiffness
Altered mental status
Non-blanching rash
Digital ischaemia
Purpura fulminans (meningococcal sepsis)
Meningism (the triad of headache, neck stiffness and photophobia) may be seen in older children but is rarely seen in younger ones.
What organisms most commonly cause meningitis in children?
> 3 months
- BACTERIAL CAUSES:
1. Neisseria meningitidis
2. Haemophilus influenzae type b
3. Streptococcus pneumoniae
4. M. tuberculosis
- VIRAL CAUSES:
Enterovirus
Herpes simplex virus
Varicella zoster virus
HIV
Lymphocytic choriomeningitis virus
EBV
CMV
Mumps
What are the pathophysiological changes associated with septic shock?
Shock develops due to circulatory, cellular and metabolic dysfunction.
Consequences include profound vasodilation, activation of inflammatory and coagulation cascades, capillary leak and dysfunctional oxygen utilisation at a cellular level.
What is the initial plan for fluid resuscitation in a child with meningococcal sepsis?
IV (or IO) access x 2
Fluid resuscitation with balanced crystalloid boluses of 5-20ml/kg titrated to peripheral perfusion, age-appropriate haemodynamic indices and lactate
Anticipate a total of up to 40-60ml/kg fluid boluses in the first hour of resuscitation in sepsis
If no resolution after 40ml/kg of boluses then manage as fluid-refractory shock.
What antibiotic and dose is required for treatment of meningococcal sepsis in children?
IV antibiotics
<1 months: IV cefotaxime 50mg/kg + IV amoxicillin 60mg/kg
> ## 1 months: IV ceftriaxone 80mg/kg± appropriate Herpes simplex treatment if suspected viral meningitis e.g. IV aciclovir 20mg/kg
± PO/NG rifampicin 10mg/kg for those who are moribund (e.g. PICU), have suspected pneumococcal resistance or have recent foreign travel
± appropriate TB treatment
What other medications can be given in meningococcal sepsis to reduce neurological sequelae?
Dexamethasone 0.15mg/kg (max 10mg/dose) in suspected bacterial meningitis
Give QDS for 4 days if CSF frankly purulent, CSF WCC >1,000/μL, protein >1g/L or gram stain positive
Ideally start dexamethasone before antibiotics
Do not start dexamethasone >12hrs after starting antibiotics
—-> May need hydrocortisone 25mg/m2 QDS for refractory shock on PICU
How can you manage fluid-refractory shock in meningococcal sepsis?
Start peripheral adrenaline
0.05 - 0.3 μg/kg/min
with close monitoring of the limb into which it is being infused
Prepare for invasive ventilation in order to gain control and facilitate central access
Once central access obtained, use either:
Adrenaline 0.1μg/kg/min (up to 1μg/kg/min) if ‘cold’ shock i.e. cold peripheries, narrow pulse pressure and suggestion of poor cardiac output
Noradrenaline 0.1μg/kg/min (up to 1μg/kg/min) if ‘warm’ shock i.e. vasodilated, wide pulse pressure
If a septic child remains hypotensive with inotrope resistant shock what drugs can be considered?
- Hydrocortisone
- Management of toxic shock syndrome e.g. IV clindamycin + IVIg
- Anaerobic cover e.g. metronidazole for gut pathology
- Investigation for other causes of shock e.g. haemorrhage, adrenal insufficiency, hypothyroidism
What are the common complications of meningococcal sepsis?
Mortality in range 5-10% within 48hrs even with early diagnosis and institution of therapy.
Hearing loss (8%); arrange audiology review as soon as possible after diagnosis of bacterial meningitis (within 4 weeks).
Skin scarring (18-55%)
Amputations (3-8%)
Other neurological sequelae; visual loss, persistent cognitive dysfunction, cranial nerve palsies.
Why is CT brain usually indicated in suspected meningitis?
CT brain usually indicated to detect alternative intracranial pathology if neurological concerns
Carried out to exclude complications of meningitis which will make LP risky if there is clinical suspicion of raised ICP:
E.g. subdural collections as in H. influenzae meningitis
E.g. obstructive hydrocephalus in M. tuberculosis meningitis
E.g. evidence of raised ICP such as ventricular effacement
May show leptomeningeal enhancement
Dose of treatment of hypoglycaemia in sepsis?
10 mls/kg of 10% Dextrose
Dose of Ketamine for induction in a child with sepsis?
0.25 - 0.5mg/ kg given slowly and titrated to effect as can still cause cardiovascular collapse.
How do you estimate a childs weight?
(AGE + 4) x 2
Paediatric ETT length
AGE / 2 + 12 (oral)
AGE / 2 + 15 (nasal)
Paediatric ETT width/ size
(Age / 4) + 4
Have cuffed and uncuffed and sizes 0.5 either side.
What is the estimated blood volume:
1. Neonates
2. Infants
3. Children
- Neonates: 90 ml/kg
- Infants: 80 ml/kg
- Children 70 ml/kg
Formula for expected Systolic BP in a child?
(Age x 2) + 80
Formula for expected MAP in a child?
(1.5 x age) + 55
This gives 50th centile
Drug dose: Adrenaline
0.1 ml/kg = 10mcg/ kg
1ml of 1:10, 000 drawn into 1ml syringe.
Drug dose: Atropine
20 mcg/ kg
Dose: Suxamethonium for Laryngospasm
0.5 - 1 mg/kg
IM Dose of Suxamethonium for laryngospasm
3mg/ kg
Paediatric Propofol dose for induction
4mg/ kg
Maintainence fluid calculation for a child?
4 , 2, 1 Rules
4ml/ kg first 10kg
2 ml/kg second 10kg
1 ml/kg every kg after this
= hourly fluid requirement.
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