JUAREZ INSTITUTE OF BIOMEDICAL SCIENCES MEDICAL COLLEGE CAREER nosology PAEDIATRIC SURG EON MEDICAL PROBLEM 5. "THE CHARGE FOR LORENA" Team members: Deyanira Galán López Varela Raul Tovar Alejandro Montes Sayta Calzadillas Olivia Alvarez Diana Muñoz Galaz Alicia Camacho González Beltrán Videyra Betancourt Me lissa Piña Vanesa Ramirez Rays Carlos Ruiz Martínez Herrada Date: April 8, 2008. Juarez Chih. Mexico Problem 5 "Lorena burden." Rosana Lorena takes her, her daughter four years the office of Dr. Romero, his pediatrician, with increasing symptoms of lethargy, fe ver and dizziness when standing is. He has presented three vomiting, no diarrhea , has not been eating well in the last 12 hours. Le typical varicella lesions ap peared five days ago, in the last 18 hours, a number of injuries of the abdomen have become red, swollen and confluent. In reviewing the doctor, Lorena lies sup ine, indifferent and confused, and seems to be very ill. Responds to the voice a nd the painful stimulation, but do not know where it is and it does not seem to understand what is said. This Tachypneic but the breathing is calm, the air seem s permeable, HR is 175 bpm, RR of 60 rpm, the rectal temperature of 39.4 º C and BP of 90/30 mmHg, the legs are hot, peripheral pulses are palpable, capillary r efill of 4 seconds. The go to the emergency room where you are given a quick cha rge of saline and antibiotics. Despite two more loads during the next hour, Lore na is deteriorating, not responding to the voice and only responds to painful st imulation. No longer palpable distal pulses and extremities are cold and cyanoti c. The heart rate varies from 170-210 bpm and BP was reported in 70/25 mmHg. CONCEPTS: Lethargy. Varicella lesions typical. Heart Rate. Respiration. Blood Pr essure. Saline. Lethargy. Prolonged state of drowsiness caused by certain diseas es. Clumsiness, drowsiness. Symptom of nervous diseases, infectious or toxic, ch aracterized by a state of deep and prolonged drowsiness. Typical lesions of chic kenpox. Are distributed according to one or more dermatómeras sensitive, and pre sent the duality itching - pain. The most characteristic sign of chickenpox is a rash that appears in the form of tiny grains that soon turn into blisters (flui d-filled blisters). Heart Rate (normal). Sleep: Newborns: 100 to 160 beats per m inute Children 1-10 years: 70-120 beats per minute Children over 10 years and ad ults: 60 to 100 beats per minute Athletes: 40 to 60 beats per minute. Respiratio n Rate (normal). Children 2-6 years 15 to 25 rpm. Blood Pressure (normal). Children 2-6 90-110 systolic diastolic 60-70. Saline. A solution is a liquid containing a dissolved body, in the case of the saline or saline, which is distilled water is 0.6 to 0.75% salt. DEFINITION OF THE PROBLEM : We know that Lorraine goes to seek medical attention for her daughter for four years, presenting neurological symptoms, metabolic and digestive. It also prese nts a clinical picture of chickenpox a few days without any treatment of evoluti on apparently, which in the last hours he had complicated injuries and vital sig ns are deteriorating despite the initial treatment in the emergency room. Brains torming: Dehydration. Gastroenteritis. Varicella. Septic shock. Encephalitis. Ca rdiovascular Diseases. Cerebellar Ataxia. Bacterial infection. SUMMARY OF IDEAS: The health problem of Lorraine began with a viral infection of chickenpox which did not receive adequate attention and complicate reaching a crash box. APPROAC H OF LEARNING OBJECTIVES: It was agreed to investigate the clinical picture of c hickenpox and its complications, Plans hydration states during the collision, th e normal values of vital signs at various ages, the resistance of vessels edo bl ood in shock, oxygenation and the treatment to follow for this case. Self-Study: --------------------- VARICELLA COMPLICATIONS - Superinfection-SEPTIC SHOCK OR TOXIC (Staphylococcus) (Streptococcus) Neurologist (cerebellar ataxia) (Encephalitis)

DIAGNOSTIC TREATMENT METHODS CHICKEN POX: The varicella-zoster virus (VZV) can cause two diseases: chickenpox resulting from primary infection and herpes zoster virus which results from its revival. VZV belongs to the herpes virus with which it shares the characteristi c of persisting in the body after primary infection and can reactivate later if for any reason there is a depression of cellular immunity.€It is an exclusively human virus to be the man the only reservoir and source of infection. Epidemiolo gy: Chickenpox is a cosmopolitan disease, highly contagious, prevalent in childr en in whom it is usually benign. It is an endemic disease with periods when it b ecomes epidemic. Virtually all individuals are infected in the course of his lif e, it is estimated that in urban areas 90% of those aged 30 years and almost eve ryone over 60 have antibodies to VZV. It is spread by direct contact with skin i njuries and inhalation of respiratory secretions containing the virus. The conta gious period extends from 1 or 2 days before the rash until the appearance of cr usts. In the adult and child under 2 years the disease is usually more serious b ecause they are more frequent complications. It is especially serious in people at high risk (ill hemato-oncology, organ transplant recipient treated with immun osuppressive drugs, AIDS and diabetes) and may also be in the pregnant woman. Th e rate of subclinical infections is only about 4%. Mechanisms of Contagion: Its transmission is mainly by three mechanisms: 1) Drops Flugee: Inhaling droplets p roduced when an infected person speaking or coughing. This is the most common fo rm of infection. The infected person is contagious from 1 or 2 days before rash onset (but even up to 4 days before) and up to 6 days after the first lesion app eared on the skin. Patients with herpes zoster may also transmit the virus throu gh respiratory secretions. (2, 3, 5, 9) 2) Direct contact with skin or mucosa: T ouching the skin lesions (vesicles) of the patient. or contact with the fluid in the blisters or contaminated objects (tissues, pacifiers, etc.).. (1) Patients with chickenpox are contagious from about two days before the rash appears until all skin lesions have crusted (usually 4-5 days). 3) transmission from infected mother to fetus during pregnancy. Of all newborns of pregnant women who have had chickenpox, 2% develop the congenital varicella s yndrome clinic: The incubation period lasts 12 to 20 days and is asymptomatic. I t follows the prodromal period, which lasts from hours to three days, during whi ch the symptoms are nonspecific: low-grade fever, headache, anorexia, vomiting. The statement period is characterized by the appearance of skin rash, mucosal le sions consisting of erythematous, erythematous papules in 24 hours develop into blisters. They are of variable size and shape, tight, clear fluid content, simul ating "dew drops" and are surrounded by a pink areola. Then lose tension and con tent becomes cloudy, but no pus. For the 2-4 days become crusty and 4-6 days wit hout scarring emerge. It is characteristic of chickenpox lesions regional polymo rphism. This is because the lesions appear in successive outbreaks in relation t o viremia and therefore are at different developmental stages. These lesions pre dominate in the head and trunk, so the outbreak of this disease is centripetal. In the immunocompetent patient after 5 days of onset of the rash and no new lesi ons. The duration of illness is 2-4 weeks. Complications occur by direct action of virus, immune mechanism or bacterial infection. The places where they see mos t often are: skin, respiratory and nervous system. Often superinfection of skin lesions especially beta-hemolytic Streptococcus, but also by other germs of the skin S. aureus or the environment. A level of the lung may occur with viral pneu monitis intersticionodular standard (chest radiograph). It is a serious potentia lly fatal complication, more common in adults, infants and immunocompromised pat ients. Sometimes it is diagnosed it can be asymptomatic and revealed only by che st radiograph. Bacterial pneumonias are late and the entry of the germ is provid ed by the viral lesions of the respiratory mucosa. In regard to the neurological complications are described: encephalitis, cerebritis, meningitis, transverse m yelitis, Guillain Barre syndrome, Reye syndrome. The pathogenesis of these is no t well defined, specifying the direct action of virus and immunological mechanis ms. The cerebellar ataxia is most common in children, usually presents in the we

eks following the eruption and evolution is usually benign. Encephalitis is more common in adults and potentially fatal. Other complications include myocarditis , pericarditis,€hepatitis, nephritis, hemorrhagic diathesis. Hemorrhagic Varicel la: This is a severe form of chickenpox where the blisters have hemorrhagic cont ent, there are petechiae, bleeding and thrombocytopenia suffusions with CID mech anism. Varicella in the immunocompromised: VZV can cause serious illness in peop le with impaired cellular immunity (hematologic or solid tumors, use of steroids in high doses, cytostatics or radiotherapy, immunosuppression that follows transplantation, AID S). The risk of spread is greatest when lymphopenia is less than 500/mm3. Seriou s illness means a shorter incubation period, the appearance of new vesicles afte r 5 days of onset of the rash of chicken pox lesions spread hemorrhagic visceral predominant in lung, liver and nervous system. Specific Treatment: Acyclovir gi ven early, up to 24 hours of onset of rash, decrease the appearance of new lesio ns and visceral dissemination. It is not indicated routinely given in immunocomp etent individuals. It is recommended for: premature infants, adolescents, adults , pregnant women, patients with lung disease and chronic skin or immunocompromis ed. Tables serious or potentially serious is preferable to intravenous infusion at a dose of 5-10 mg / k every 8 hours. When administered orally, the dose is 80 0 mg five times daily. The duration of treatment is between 5 and 10 days. Valac yclovir has greater bioavailability and is equally effective than acyclovir. It is administered at a dose of 1 g V / 0 c / 8 hours. We recommend not giving aspi rin to the risk of Reye syndrome. The treatment must be complemented with genera l measures of hygiene. Ataxia: Ataxia is a deliberate movement disorder characte rized by abnormalities of balance and coordination. When this disorder is eviden t during the execution of movement, it is called kinetic ataxia, whereas if it o ccurs during walking or standing position, we speak of static ataxia. Acute cere bellitis: Also called postinfectious acute cerebellar ataxia. Transient cerebell ar dysfunction is more common in children <5 years. There is usually a prior inf ectious process (1-2 weeks). Viral infections involved are: chickenpox, enterovi rus, herpes, mycoplasma. They pancerebelitis (static and kinetic ataxia). CSF an d EEG (needed to rule out other processes) are normal (50% mild CSF pleocytosis of more than 5 elements). Tables are self-limited, 1 month of evolution, which h eal without sequelae and therefore do not require treatment. Encephalitis: is ac ute inflammation of the brain. Its origin in most cases viral, although it shoul d be a differential diagnosis with other infectious and noninfectious causes. We estimate the incidence of acute viral encephalitis in childhood about 810 cases / 100,000 inhabitants / year, being more frequent in children under 2 años.160 analyzing the etiological distribution by age, infants in which a majority of ca uses encephalitis unknown, as well as those caused by enterovirus and herpes sim plex. In older children predominantly encephalitis from measles, mumps and rubel la to the introduction of MMR immunization. There are now more frequent varicell a encephalitis, adenovirus and Mycoplasma pneumoniae. Unlike adults, in children there is a higher incidence of encephalitis, most diverse etiology and better o verall prognosis. The CNS injury can occur by two mechanisms: - Primary Encephalitis: direct cell injury due to viral toxicity. It is the fund amental mechanism of viral encephalitis. - Encephalitis post and parainfectious: Depends on patient's immune response, no virus was isolated in the CSF. It is t ypical of encephalitis following immunization or after rash diseases. SEPTIC SHO CK This condition is secondary to the systemic effect of the response to a serio us infection. Its pathophysiology is complex and involved the patient and inflam matory mediators release products of the germ. His treatment tends to the preven tion or early detection. Their morality is about 40-60% depending on the underly ing pathology. Not all serious infection is accompanied by shock and no shock at all serious is septic infection by first intention. It is important to recogniz e that septic shock is part of a succession of events within the framework of se rious infection, so they define each of these is important. NEW DEFINITIONS.€Inf ection: The Phenomenon of the host inflammatory response characterized by the pr

esence of microorganisms or sterile tissue invasion by these organisms Bacteremi a: Presence of viable bacteria in the blood. Systemic inflammatory response synd rome. (SIRS). Systemic inflammatory response to severe clinical damage. SIRS is manifested by two or more of the following: temperature> 38 degrees Celsius. HR> 90 beats per minute. FR> 20 breaths per minute Leukocytes> 12,000 or <4000> 10% immature white blood cells. SIRS due to infection. Sepsis: Severe sepsis Sepsis associated with organ dysfunction, hypoperfusion or hypoten sion. This includes but not limited to, lactic acidosis, oliguria or acute alter ation in the metal state. Septic shock: Sepsis with hypotension despite adequate fluid replacement, coupled with the presence of perfusion abnormalities that in clude, but are not limited to, lactic acidosis, oliguria or acute alteration in mental status. Patients who are under management with inotropes, may not be hypo tensive at the time that perfusion abnormalities are measured. Hypotension: syst olic pressure below 90 mm Hg. or reduction of more than 40 mm Hg. baseline measu rements and the absence of other causes of hypotension. Multiple organ dysfunction syndrome: Presence of altered organ function in a cri tically ill patient such that homeostasis can not be maintained without interven tion. CAUSES Almost every type of organism has the potential to cause the syndro me or septic shock, but most cases are caused by gram negative bacilli. Pseudomo nas aeruginosa is the most common gram negative microbe isolated, followed by St aphylococcus aureus and coagulase-negative staphylococci in patients in the ICU. E. Coli is the organism most commonly recovered from the urinary tract of these patients. P. aeuroginosa has been consistently associated with the highest mort ality of all bacteremic infections. Recent data, however, have shown that gram-p ositive bacteremia (especially Staphylococcus) have increased in frequency, part icularly in patients with malignant tumors endovascular lines. Anaerobic bacteri al infections are less common source of sepsis or septic shock and are usually r estricted to weakened patients. Most anaerobic bacteremias are derived from sour ces intra-abdominal or pelvic (postpartum sepsis or abdominal surgery). RECOGNIT ION The manifestation of sepsis and SIRS indicates the presence of one or more f oci of inflammation related to infection in different stages, so that an approac h involving monotherapy has high chances of failure. Most patients require a var iety of interventions. The earlier therapy is instituted more likely to be effec tive. Constitutional symptoms and fever: There is not always a fever, although t he most common symptom. Some patients develop hypothermia, especially the weak, alcoholics, elderly, hepatic or renal failure or receiving steroids or immunothe rapy. Normothermia not exclude the diagnosis of sepsis or septic shock. Chills, nausea, vomiting, diarrhea and jaundice may be accompanying symptoms. Hemodynami c and cardiovascular aspects: general cardiovascular failure sets the tone. An i nitial phase of a late stage vasodilation and vasoconstriction, leading to misal location of distal flow, damage to endothelium and vascular disruption syndrome. Hypotension initially respond aggressively to liquid, but belatedly requires th e use of vasoconstrictors. The myocardium is depressed and low ejection fraction resulting in low cardiac output contributing to the crash. Initially fall in sy stemic vascular resistance and increases cardiac output, which maintains the nor mal TA. This is an early stage when the fluid response is satisfactory. If the p roblem progresses fall in SVR and the GC but can not make up more and hypotensio n. The heart is depressed by the action of mediators of sepsis and decreases the FE and ventricular dilatation occurs. The average pressure drop, although the p atient still responds to liquids. In florid septic shock increase in SVR by inte nse endogenous alpha stimulation. However, the GC starts to fall as a decomposit ion of the response heart. Hemodynamic monitoring at this stage can be very helpful to calculate sev ere ventricular dysfunction. Hematologic Changes: Leukocytosis with neutrophilia . Changes may not occur and may even have leucemioide reaction. Thrombocytopenia

is an early marker of sepsis. A low platelet count is associated with increased incidence of ARDS and septic shock.€High or normal accounts are also common. SY STEMIC EFFECTS OF SEPSIS. Pulmonary: Tachypnea is an early manifestation of seps is. The PaCO2 may be low in initial stages, secondary to hyperventilation, which masks while hypoxemia. It is important in this case calculate the Aa O2 gradien t. If it continues unchecked Sepsis is present respiratory muscle fatigue and in creased PaCO2. ARDS is a manifestation of final damage to the lungs. The criteri a for diagnosis of ARDS are: • PO2 <50 mm Hg. supplementation despite FiO2> 50%. Press in pulmonary artery wedge (PCP) normal or low. Diffuse pulmonary in filtrates. Decreased lung compliance (usually <50mm/cm. H20) Renal and metabolic: Oliguria and azotemia may complicate sepsis. Hypovolemia is generally poor perfusion. The pH in Sepsis toward acidosis may vary in direct r elation to inadequate systemic perfusion. While early stage can be seen in late stages respiratory alkalosis acidosis predominates. The anion gap is increased. There may be changes in liver function. Elevation of SGOT, SGPT and bilirubin ar e common and have negative prognostic implications. CENTRAL NERVOUS SYSTEM: ment al status changes such as confusion, lethargy and / or drowsiness and even coma are visible in sepsis and septic shock. A distinction should be possible as CNS infections. They may require CT for diagnosis or PL. History DIAGNOSIS: Infectio n may have been acquired in the community or indoor patient which marks an impor tant difference in management. Exposure to animals, travel, insect bites, alcoho l use, seizures, loss of consciousness, previous medication, underlying diseases , are data that should be taken for the diagnosis and appropriate management. Ph ysical Examination: In all neutropenic patients and in patients with suspected p elvic origin sepsis the clinician should also perform rectal exam, pelvic and ge nitals. Laboratory data: BHC, urinalysis, coagulation profile, blood chemistry, electrol ytes, LFT's, blood lactic acid, arterial blood gas analysis, EKG, chest X-ray, b lood cultures, urine, sputum, and other infected sites. Fluid gram stain infecte d or suspected to initiate empiric therapy. Two or three blood cultures in the p resence of fever and before starting antibiotics is indicated. Other studies wil l depend on each case p. Eg CT, MRI, etc. Antimicrobial therapy. Is required to initiate early in the course of the disease. Almost always starts before identif ying the type of organism and sometimes before identifying the infected site wit h precision. At least two drugs should be used to exercise adequate empirical co verage. The two drugs should be synergistic against the body and reduce the poss ibility of bacterial resistance. Once you identify the germ must adjust the sche dule of antibiotics. If the patient is neutropenic for any reason, using a penic illin anti.pseudomona. If allergic to penicillin must be used with caution a thi rd generation cephalosporin with activity against Pseudomonas plus an aminoglyco side. If anaerobes are suspected, a drug must be combined with coverage as Cefox itin, Metronidazole or Clindamycin. If there is suspicion of a beta-lactamase re sistant Vancomycin should be added to the schema. Surgical drainage: All suspici ous sites should be drained. All catheters or prostheses under suspicion should be removed or changed if necessary. Monitoring in the ICU. Swan-Ganz catheters m ay be useful in the management, although there is currently controversy in its u se. Ventilation may need help with mechanical ventilation and special methods of cycles. The indications for intubation in septic shock are poor oxygenation des pite high FiO2, retention of CO2 by respiratory fatigue or failure to maintain n ormal oxygenation and pH. Cardiovascular management: aggressive fluid resuscitat ion and amines are necessary in management. Invasive monitoring that makes some patients require should be managed in the ICU. The type of fluid is controversia l. Isotonic solutions are recommended. Colloid or albumin may reduce the inciden ce of pulmonary edema but its use and usefulness should be in charge of intensiv e care physicians. The inotropes used are dopamine, dobutamine, adrenaline and n oradrenaline all infusion. The drug that is commonly used onset septic shock is dopamine. The dose is increased quickly because the response must be submitted w ithin 5 min. The dose of 3-5 mcg / kg / min.€presumed dopa stimulates receptors


in the splanchnic bed, causing vasodilatation and increased flow. It has been us ed and abused of this property in patients with low diuresis in different clinical conditions. Doses of 5-10 mcg / kg / min. is assumed to stimulate the B1 and B2 receptors i ncreases heart rate and moderate bronchodilation. Higher doses of 10 mcg / kg / min. is assumed to stimulate the receptors a and increase peripheral resistance and blood pressure. It uses up a dose of 20 mcg / kg / min. In this situation, w hich is preferred to add epinephrine or norepinephrine infusion. The Dobutamine is a drug acting on B1 and B2 receptors and is used in septic shock, once the TA has been improved, either liquid or inotropic support. Its main action is to in crease cardiac output and thus increase systemic oxygen delivery. The adrenaline infusion is the drug of choice in cardiogenic shock especially after the depart ure of cardiopulmonary bypass pump. Other therapeutic modalities are still being studied but have shown no change the prognosis in large series of patients. CON CLUSIONS: In this clinical case was presented to see one of the main complicatio ns of superinfection of chickenpox lesions by S. aureus, which is the most commo n pathogen in these cases. which caused a severe septicemia evolved into a state of septic shock, which is often fatal if not treated properly. The medical atte ntion that was given to this complication was correct, the use of fluids to comp ensate for the lost homeostasis by the shock and antibiotics to combat S. aureus . It is very convenient time to discern a state of shock Due its causes and mana gement. REFERENCES: www.infecto.edu.uy/revisiontemas/tema2/varicelatema.htm www. hrrio.cl/clinicos/Protocolos/ .-% Protocol% 20Varicela 2025. www.amro.who.int/Sp anish/ DD / PUB / Complicaciones_varicela www.neurologiauruguay.org/congreso/ jo bs / documents / work http://db.doyma.es/cgi-bin/wdbcgi.exe/doyma/mrevista. abst ract? pident = 13050601 http://kidshealth.org/parent/en_espanol/infecciones/chic ken_pox_esp.html http://www.hospitalcruces.com/informaciongestion/pediatria/pedi atria/vertigo.htm http://www.prodigyweb.net .mx / Galaxis / manejo_choque.htm ht tp://www.scribd.com/people/view/355388-raul-alonso-varela-alvarez