Shock

“Worldwide, hypovolaemic shock is the most common type seen in children, largely due to dehydration. In the developed world however, septic shock is the most common and remains a significant cause of morbidity and mortality.”

EM Curriculum: (click to view)

BACKGROUND

The term shock describes inadequate tissue oxygen delivery due to a reduction in tissue perfusion. Hypoxia within the cell forces it into adopting anaerobic metabolism leading to the production of lactic acid.

The work by the Surviving Sepsis Campaign clearly shows that early and aggressive fluid resuscitation along with administration of antibiotics and goal directed therapy can significantly reduce adverse outcomes.

Despite this, evidence suggests that in both children and adult patients these targets are often not met. It is essential as Emergency physicians that we rapidly identify and manage patients with sepsis to ensure the best possible outcomes.

LEARNING OUTCOMES FROM COMPLETING THE TASKS

  • Understand local guidelines for DKA in children and be able to prescribe insulin and fluids accordingly.

  • Recognise the features of cerebral oedema and institute initial management.

  • Know the causes of both upper and lower GI bleeding in children.

  • Be able to formulate a differential diagnosis for the shocked child.

  • Understand the pathophysiology, classification and management of septic shock in children.

LEARNING OUTCOMES FROM FACE-TO-FACE TEACHING

  • Have a structured approach to the shocked child.

  • Assess and initiate immediate management of a septic child.

  • Be able to stabilise a child who is haemodynamically compromised.

  • Understand the different options available to secure vascular access in a child with haemodynamic compromise e.g. IO & EZ-IO, peripheral cannulae, scalp cannulae, central access options.

TASKS

Complete the following before the face to face session:

TASK 1: Shock, sirs and Sepsis

Duration: 60 mins

These two pages from UpToDate® give a comprehensive but succinct review of Shock, SIRS and Sepsis in Children. There are lots of links within the pages to other UpToDate® resources.

Damian's Video is A guide the Leicester Royal Infirmary Children's Emergency Department Sepsis pro forma.
A previous video on sepsis is available with a more generic overview.

A guide the Leicester Royal Infirmary Children's Emergency Department Sepsis Proforma. We would welcome other units approaches and outcomes to this challenge. A previous video on sepsis is available https://www.youtube.com/watch?v=CZAsYQLGeXI with a more generic overview. This is part of the Emergency Medicine East Midlands Educational Media Programme.

TASK 2: Gastrointestinal bleeding in children

Duration: 45 mins

Read this webpage which gives a useful overview of gastrointestinal bleeding in children.

Then listen to this podcast on Intussusception by empem.org.

TASK 3: Button Battery Ingestion

Duration: 35 mins

Hopefully you will all be aware of the danger of button battery ingestion, however the following cover important points for anyone who sees children in the ED.

Task 4: Diabetic ketoacidosis

Duration: 20 mins

Read this document covering treatment of DKA in patients under 18 years of age. It is based on the NICE guideline from August 2015.

#EM3 Content

Lightning Learning:

Simblog:

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“A 27 day old baby is brought in by her mother as she has not been feeding well today and now will not stop crying.”
“A 6 year old girl is brought in by her family with vomiting and lethargy. They are concerned as she hasn’t managed to drink much at all today and has been quite sleepy.”

ADDITIONAL RESOURCES

Here are some extra resources to review if you want more information:

eUHL: Upper GI bleeding e-Learning module

This module has been written by two of the senior gastroenterology trainees in Leicester and can be accessed through your eUHL account.

SIGN guidelines on Upper GI Bleeding

Guideline for the management of upper GI Bleeding

Podcast: Pediatric Upper GI bleeding

An excellent summary of the causes and management of upper GI bleeding in children. The podcast is 45 mins long.

NICE Guideline NG18

Diabetes (type 1 and type 2) in children and young people: diagnosis and management.

SMART EM PODCAST: PPI'S IN ACUTE GI BLEEDING

An enlightening look at the evidence on PPI's in UGI bleeds – should we be using them at all?

CATS GUIDELINE SEPTIC SHOCK IN CHILDREN

A nice easy to read document that covers the important points of Surviving Sepsis Guidance.

UPTODATE®: INTUSSUSCEPTION IN CHILDREN

A good overview of intussusception in paediatric patients.

BSPED DKA CALCULATOR

A useful one page aide-memoire to use if treating a patient with DKA.

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: