Article: TME200223 Date: October 23, 2013 Time: 14:42

Advanced Emergency Nursing Journal

Vol. 35, No. 4, pp. 303–313
Copyright 
C 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cases
O F N O T E
Column Editor: Theresa M. Campo, DNP, APN, NP-C, CEN

Pediatric Sepsis
A Case Study
Francesco Umbriaco, RN, BSN, BS, TNCC
Colleen Andreoni, DNP, FNP-BC, ANP-BC, CEN

Abstract
Abdominal pain with vomiting is a common pediatric complaint in the emergency department setting
that can lead to a more insidious disease state. The article depicts a case study of a 21-month-old
male child presenting with these signs and symptoms that ultimately resulted in a diagnosis of septic
shock. The importance of physical assessment, rapid response to findings with time-constrained
empirical interventions, the relevance of pediatric sepsis to the provider, the consideration of access
to health care, and a holistic approach to treatment of the patient and the family are highlighted. The
application and explanation of evidence-based guidelines is also depicted in the management of the
patient. Key words: abdominal pain, pediatric sepsis, pediatric(s), sepsis, septic shock, shock

I
N THE emergency department (ED) en-
vironment, abdominal pain and vomiting
are some of the most common pediatric
complaints. These presentations are the prin-
cipal complaint of 6.8% of ED visits across all
age groups (Tintinalli, Stapczynski, Ma, Cline,
& Meckler, 2011a). The differential diagnoses
can be expansive with a wide variation of
severity of illness and injury.
The case study presented herein illustrates
the importance of initial assessment, metic-
ulous investigation, rapid empiric treatment,
Author Affiliations: Emergency Department, Advo-
cate Trinity Hospital, Chicago, Illinois (Mr Umbriaco);
and Loyola University Chicago, Marcella Niehoff School
of Nursing, Chicago, Illinois (Dr Andreoni).
Disclosure: The authors report no conflicts of interest.
Corresponding Author: Francesco Umbriaco, RN,
BSN, BS, TNCC, 9311 S. 86th Court, Hickory Hills, IL
60457 (fumbria@luc.edu).
DOI: 10.1097/TME.0b013e3182aa05a0
and using evidence-based guidelines for chil-
dren presenting with sepsis.
A CRITICALLY ILL CHILD: CASE IN REVIEW
History of Present Illness: Patient Presentation
T.B. was a 21-month-old male child who
presented to a community ED through triage
with his mother. The mother stated that she
was concerned that her son “had the flu.”
The mother stated that he had a fever that she
noticed that morning and had not been eating
well since the previous night. She indicated
that her son vomited green fluid once that
morning and was complaining of abdominal
pain. The mother explained that she had
responsibility for T.B. from Monday to Friday,
and the grandparents watched him on the
weekends. It was Saturday morning. The
mother reported that she and T.B. had been

303

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Article: TME200223 Date: October 23, 2013 Time: 14:42

304 Advanced Emergency Nursing Journal

“staying at the casino for the last four days, he
was running around and playing the whole
time until last night.” The mother appeared
detached from T.B. and said that she “only
came because my father told me to.”
The initial visual assessment, also re-
ferred to as the pediatric assessment triangle
(PAT), performed by the triage nurse, quickly
determined that this child was unstable. See
Table 1.
Past Medical History
Once in the treatment room, the mother de-
nied any past medical history or surgical pro-
cedures. There were no known complications
at birth, the delivery was a normal sponta-
neous vaginal delivery, and birth occurred at
39 weeks of gestation. The patient was up to
date on his required childhood immunizations
but had not received a flu vaccination within
the last year. T.B. had no siblings. His mother
denied alcohol or drug use during pregnancy
or currently. She was a single mother, unem-
ployed, uninsured, and a poor historian. T.B.’s
mother denied any known allergies for him
and stated that he did not take any medica-
tions regularly. She had not given him any-
thing for the present illness because “it just
came on this morning.”
Physical Examination
Initial vital signs were as follows: Tempera-
ture: 39.2 ◦ C (102.6 ◦ F); rectal heart rate (HR):
190; apical respiratory rate (RR): 35; pulse
oximetry: 98% at room air, which was within
normal limits; blood pressure: 101/54 mmHg;
weight: 15.4 kg/33 lb 15 oz (greater than 90th
percentile); and capillary refill less than 2 s.
The immediate general impression of the
patient was that he appeared poorly cared
for as evidenced by soiled clothes and lack
of cleanliness. He was well developed and
well nourished but, more importantly, ap-
peared toxic as evidenced by his poor re-
sponse to interaction and listlessness. Upon
further examination, the patient’s skin was
dry, dusky, and appeared ashen. His face
was symmetrical, the anterior fontanel was
soft and sunken, and the posterior fontanel
was closed. The head was normocephalic
without deformity, the neck was supple, the
trachea was midline, and no cervical lym-
phadenopathy or thyromegaly was palpated.
He was unable to follow objects with his gaze,
and his pupils were dilated with sluggish re-
sponse to light. He did not produce tears,
even when agitated. T.B.’s ear canals were
patent and his tympanic membranes were in-
tact and clear with no pre- or postauricular

Table 1. Pediatric assessment triangle (PAT) at the time of triage

PAT Component Observed Signs

Appearance Tone: Listless, lethargic

Work of breathing
Circulation to the skin
Interactiveness: Poor, does not raise his head from mother’s shoulder
Consolability: No differential response between triage nurse and mother
Look/gaze: Nonfocused
Speech/cry: None
Airway sounds: No abnormal sounds
Positioning: No preference for posture
Nasal flaring: None
Pallor: Dusky skin color
Mottling: None
Cyanosis: None

Note. PAT = pediatric assessment triangle. From “The Pediatric Assessment Triangle: A Novel Approach for the Rapid
Evaluation of Children,” by R. A. Dieckmann, D. Brownstein, and M. Gausche-Hall, 2010, Pediatric Emergency Care,
26, pp. 312–315.

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Article: TME200223 Date: October 23, 2013 Time: 14:42

October–December 2013 r Vol. 35, No. 4 Pediatric Sepsis 305

lymphadenopathy. The nares were crusted
and inflamed, the nasal airway was patent,
and his oral mucosa was dry with cracked lips.
The neck was supple with a full range of mo-
tion and no meningismus or nuchal rigidity.
Lung sounds were clear and equal bilaterally,
and no respiratory distress was noted. The
patient’s pulse was rapid, regular, bounding,
and symmetrical when centrally palpated in
the femoral region. The heart tones were nor-
mal with no murmurs or gallops. There was
no cyanosis, and his capillary refill time was
less than 2 s. The abdomen was distended and
rigid with hypoactive bowel sounds. There
was no bruising or signs of obvious trauma,
and the mother could not recall the last bowel
movement. Upon palpation, there was invol-
untary guarding, with no masses or peristaltic
movements noted. Upon inspection of his
back, there was no spinal or costovertebral
tenderness. His diaper was dry and did not
appear to have been changed for some time.
The external genitalia were normal, with no
rash or hernia noted. The patient moved all
four extremities against gravity but not resis-
tance and had a flaccid muscle tone with weak
bilateral grasps. The neurological assessment
was limited to observation of a weak cry and
minimal response to pain when peripheral in-
travenous (PIV) access was obtained. Initial
Glasgow Coma Scale score for this patient
was 9, with eyes opening spontaneously, no
speech, and withdrawal from pain (Teasdale
& Jennett, 1974). See Table 2.
Initial Management
The triage nurse administered ibuprofen 154
mg orally (10 mg/kg) for the fever per the
hospital policy. When obtaining vital signs,

Table 2. Physical assessment

General Unkempt, soiled clothing, unclean appearance.

Skin Warm, pale. No petechiae, no purpura, or other rash or lesions. No abnormal
bruising or signs of obvious trauma.
Head Face was symmetrical; anterior fontanel was soft and sunken, posterior
fontanel closed; and head was normocephalic, without deformity. The neck
was supple, trachea midline, and no cervical lymphadenopathy or
thyromegaly was palpated.
Eyes Unable to converge or follow objects. Pupils dilated and sluggish to light
response. No tears when child was agitated.
Nose Crusted, red nares. Nostrils bilaterally patent. No trauma or epistaxis.
Mouth Oral mucosa was pale and dry, with cracked lips.
Neck Supple; full range of motion; no meningismus or nuchal rigidity.
Chest/lungs Clear to auscultation bilaterally. No accessory muscle use, grunting, head
bobbing, nasal flaring, or retractions.
Cardiovascular Rate was rapid and regular. No cyanosis. Heart sounds clear with normal S1
and S2 with no murmur. Femoral pulses bounding, and symmetric
bilaterally. Capillary refill less than 2 s.
Abdomen Distended, rigid. Hypoactive bowel sounds. Involuntary guarding to palpation,
with associated wincing. No masses palpated. No peristaltic movements.
Back No signs of trauma; no spinal or costovertebral tenderness.
Genitalia No evidence of trauma. Bilateral testicles descended and foreskin retracts
easily. Diaper was dry and appeared as though it has not been changed for
some time.
Musculoskeletal Moving all four extremities against gravity but not resistance. Weak grasp and
generalized flaccid tone. No obvious deformities.
Neurological Minimal response to painful stimuli (intravenous insertion). Weak cry,
minimal interaction with environment. Nonverbal.

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Article: TME200223 Date: October 23, 2013
306
the triage nurse noticed that the child had not
made any verbal sounds and asked the mother
whether the child speaks. The mother stated,
“You know, it is the weirdest thing . . . usu-
ally he doesn’t stop talking but for the last
two days he hasn’t said a word.” The triage
nurse recognized this as a possible indica-
tion of lethargy, and the patient was promptly
brought to an ED treatment room for immedi-
ate attention by the health care team.
Upon completing the triage information,
T.B. was given an Emergency Severity Index
score of 2, as the triage nurse recognized
that this was a high-risk patient with an al-
tered mental status manifesting as lethargy
and aphasia that required immediate interven-
tions (Gilboy, Tanabe, Travers, & Rosenau,
2012). The physical examination was com-
pleted by the primary ED nurse while T.B.
was being undressed in the treatment room.
A pediatric crash cart was also brought to
the treatment room upon recognition of the
severity of this child’s illness. The pediatric
crash cart equipment was organized accord-
ing to weight and correlated with recommen-
dations of a length-based weight resuscitation
tape (Broselow & Hinkle, 1993).
A pulse oximeter, a heart monitor, and a
blood pressure cuff were placed upon dis-
robing the patient. A 22-gauge PIV catheter
was placed in the left antecubital area, blood
was drawn for laboratory analysis, and the
site was secured with an arm board. Urinary
catheterization was carried out with 6 ml of
urine initially collected. A nasal swab for rapid
influenza/respiratory syncytial virus testing
was also collected. The bedside glucose
result was 109 mmol/L. A complete blood
cell count, complete metabolic panel, blood
type and screen, blood cultures, and a urine
toxicology panel to rule out possible drug
ingestion as the cause of lethargy and altered
mental status were ordered STAT. Fluid
resuscitation with 0.9% normal saline was
initiated at 20-ml/kg rapid infusion (300-ml
intravenous bolus). Antibiotic treatment was
begun immediately following collection of
blood culture specimens. As bacterial menin-
gitis, antibiotic-resistant infection strains, and
septicemia were not yet ruled out, ceftri-
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Time: 14:42
Advanced Emergency Nursing Journal
axone 1.5 gm intravenously (over 30 min)
and vancomycin 150 mg intravenously (more
than 90 min) were ordered. These antibiotics
were used as broad-spectrum, empirical
coverage for gram-positive (vancomycin) and
gram-negative (ceftriaxone) organisms. Ac-
etaminophen 230 mg orally (15 mg/kg) was
also administered for further fever reduction.
Laboratory Results
The results of the laboratory tests began to
arrive while empirical treatment was car-
ried out. Results of the urine toxicology
panel were negative, and no salicylate or
acetaminophen levels were detected. The
abnormal metabolic panel findings included
carbon dioxide of 12 mmol/L (low), anion
gap of 31 mmol/L (high), and creatinine of
1.30 mg/dl (high). The complete blood cell
count reported a white blood cell count of 4.5
× 103 /mcl (low), with zero neutrophils both
segmented and absolute. His hemoglobin was
12.4 g/dl, hematocrit was 38.7%, and an el-
evated lymphocyte count of 89%. The rapid
influenza screen was positive for influenza A.
Imaging
An abdominal computed tomographic (CT)
scan was ordered to evaluate the rigid ab-
domen with involuntary guarding, a head CT
scan was ordered to evaluate the altered men-
tal status and flaccid tone, and a chest radio-
graph was ordered to rule out pneumonia
or other cardiopulmonary causative factors.
The radiologist read the chest radiograph and
the head CT scan as normal. The radiologist’s
impression of the abdominal CT scan was
a distended stomach, with mildly distended
multiple segments of small bowel suggestive
of small bowel obstruction or ileus and dis-
tal esophageal mild dilation and fluid content
consistent with vomiting.
DISCUSSION
All of these results were supportive of a diag-
nosis of sepsis with leukopenia, neutropenia,
and metabolic acidosis with respiratory com-
pensation. The diagnosis of sepsis was not
 Article: TME200223
October–December 2013 r Vol. 35, No. 4
solely based on laboratory findings. Serwint,
Dias, Chang, Sharkey, and Walker (2005)
found that leukopenia or neutropenia alone
in the febrile child is not associated with sep-
sis. Rather, it is the culmination of the clini-
cal judgment, physical findings, and review of
the complete blood cell count that identifies
significant disease (Serwint et al., 2005). T.B.
was leukopenic and febrile, with an altered
mental status that further suggested sepsis.
Case Progression
T.B.’s vital signs were stable for the next
30 min. Then, abruptly, T.B. vomited bil-
ious fluid and his heart rate decreased to less
than 60/min while his blood pressure became
undetectable and his breathing was agonal.
Cardiopulmonary resuscitation (CPR) was be-
gun, the patient was placed on a monitor/
defibrillator with pediatric pads, and a size
4.0 endotracheal tube was placed by the
ED physician using 23.1 mg of ketamine
(1.5 mg/kg) for rapid intubation. Placement
was verified by two confirmatory methods:
chest radiograph and positive colorimetric
change identified on the end-tidal CO2 de-
tector immediately following intubation. This
was consistent with the American Heart Asso-
ciation’s (AHA’s) Pediatric Advanced Life Sup-
port (PALS) guidelines (AHA, 2011) to con-
firm endotracheal position in children.
Atropine 7.7 mg (0.5 mg/kg) intravenously
was given, and a second 22-gauge PIV catheter
was placed in the right antecubital area. A
second intravenous fluid bolus was begun
(300 ml). The current AHA PALS guidelines
(2011) recommend the use of epinephrine for
bradycardia associated with poor perfusion.
Atropine is indicated when the bradycardia
is associated with increased vagal tone. T.B.’s
bradycardia was immediately precipitated by
vomiting; thus, the use of atropine was con-
sistent with the current guidelines. Intubation
may also stimulate a vagal response, with at-
ropine recommended as an adjunct during
intubation.
The resuscitation efforts continued for 4
min until T.B.’s blood pressure and heart rate
were normalized. A surgeon from a pediatric
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Date: October 23, 2013 Time: 14:42
Pediatric Sepsis 307
tertiary care facility was consulted for this crit-
ically ill child, because of an abnormal abdom-
inal CT and possible sepsis. He agreed to ac-
cept T.B. in transfer and arranged for admis-
sion directly to surgery. The critical care pe-
diatric transport team arrived within 15 min.
T.B. was transported with 0.9% normal saline
fluid boluses infusing through both access
sites, as well as the intravenous vancomycin.
Vital signs at the time of transfer were
as follows: HR: 124, RR: 25 via ventilator;
pulse oximetry: 99%; temperature: 38.2 ◦ C
(100.8 ◦ F) rectal; and blood pressure: 96/
palpable mmHg. A total fluid resuscitation of
approximately 600 ml had been delivered at
the time of departure. See Figure 1.
Medical Decision Making
Differential diagnoses considered at the time
of transfer included sepsis of unknown origin,
intussusception with obstruction, volvulus,
strangulated hernia, appendicitis, trauma, and
meningitis. Although acute abdominal pain in
children can be benign in cases such as acute
gastroenteritis or mesenteric lymphadenopa-
thy, these were excluded, given the patient’s
septic presentation. Pediatric patients who
present with intractable pain, uncontrolled
vomiting, unstable vital signs, altered mental
status, and suspicion of an acute abdomen
require an emergent surgical consult. The
timeliness of consultation and transfer was
the result of an established relationship be-
tween the community hospital and the pedi-
atric tertiary care facility. The total time of
the patient’s length of stay in the ED was ap-
proximately 1 hr. Although this is the treat-
ment goal for sepsis, the transportation time
to the pediatric tertiary care facility was ap-
proximately 17 min. The initiation of empiri-
cal treatment of sepsis before transfer was an
essential component of this child’s care.
PEDIATRIC SEPSIS CONSIDERATIONS
Suspicion of Septic Shock
This case presented a pediatric patient with
possible septic shock. Multiple profes-
sional groups have created evidence-based
 Article: TME200223 Date: October 23, 2013 Time: 14:42

308 Advanced Emergency Nursing Journal

Figure 1. Case progression. BMP = basic metabolic panel; BP = blood pressure; CBC = complete blood
count; CT = computed tomography; ED = emergency department; IV = intravenously; WBC = white
blood count.

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Article: TME200223
October–December 2013 r Vol. 35, No. 4
guidelines that are continuously being re-
viewed and revised on pediatric sepsis. The
AHA with its PALS guidelines (2011), the
American College of Critical Care Medicine
(ACCM; Brierley et al., 2009), and, on a
global platform, the World Federation of Soci-
eties of Intensive and Critical Care Medicine
(Dellinger et al., 2013) have all published
well-accepted algorithms and goal-oriented
approaches that are, for the most part, in con-
cert with each other.
Suspicion of septic shock should arise from
the “triad of inflammation” with a mental
status change (Brierley et al., 2009). The
“triad of inflammation” refers to the common
signs of benign infection in children: tachycar-
dia, fever, and vasodilation. Sepsis is added
to the differential diagnoses when these
signs are coupled with irritability, drowsiness,
confusion, poor interaction with caregivers,
lethargy, or decreased arousal in the pedi-
atric patient (Brierley et al., 2009; Tintinalli,
Stapczynski, Ma, Cline, & Meckler, 2011b).
These can be difficult to detect in the pedi-
atric patient, but may manifest in a number of
behaviors. In this case, the patient had little
interaction with caregivers, did not respond
to name, was difficult to arouse, and, perhaps
most importantly, did not respond appropri-
ately to pain when a PIV catheter was placed.
Clinical diagnosis of sepsis is made when a
suspected infection is characterized by hy-
pothermia or hyperthermia, and there are
clinical signs of inadequate tissue perfusion.
The ACCM (Brierley et al., 2009) defines inad-
equate tissue perfusion into two categories:
cold shock (capillary refill more than 2 s, di-
minished pulses, and mottled cold extremi-
ties) and warm shock (flash capillary refill,
bounding peripheral pulses, and wide pulse
pressure), as well as a general finding of urine
output of less than 1 ml/kg/hr. The Surviving
Sepsis Campaign (SSC; Dellinger et al., 2013)
states that the criteria for systemic inflamma-
tory response syndrome (SIRS), considered
the precursor to sepsis, must first be met to
establish severe sepsis in a child. This requires
either temperature or leukocytic abnormal-
ity. Once this has been determined, a child
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Date: October 23, 2013 Time: 14:42
Pediatric Sepsis 309
must also have cardiovascular dysfunction,
acute respiratory distress syndrome (ARDS),
or two or more other organ dysfunctions to be
considered in severe sepsis (Dellinger et al.,
2013). The definitions of severe sepsis, SIRS,
and multiple system organ failure are similar
to adults but are age-specific to the pediatric
patient (Dellinger et al., 2013).
The role of blood pressure is an important
component in the diagnosis and treatment of
pediatric sepsis. Hypotension is not required
for diagnosis of pediatric septic shock, al-
though its presence is confirmatory (Brierley
et al., 2009). As children generally have a
lower blood pressure than adults and can
maintain an adequate blood pressure with
vasoconstriction and increased heart rate, it
cannot be used as an endpoint for resuscita-
tion (Dellinger et al., 2013). However, when
hypotension does occur, cardiovascular col-
lapse will often follow soon.
Guidelines for Treatment
Time is an important factor for pediatric
patients with sepsis. Early aggressive man-
agement with fluids, vasoactive agents, and
antibiotics within the first hour of arrival is re-
quired to reduce the mortality rate in children
(Brierley et al., 2009; AHA, 2011; Tintinalli
et al., 2011b; Parker, 2009; Dellinger et al.,
2013). The goals for emergency department
resuscitation mirror the algorithm presented
in PALS (AHA, 2011): maintain or restore air-
way, oxygenation, and ventilation. The end-
points of treatment are capillary refill of 2 s or
less, normal pulses with no difference in qual-
ity between the peripheral and central pulses,
warm extremities, urine output of more than
1 ml/kg/hr, return of normal mental status,
normal blood pressures, normal glucose con-
centration, and normal calcium concentra-
tion (Brierley et al., 2009). Pulse oximetry,
temperature, cardiac rhythm, blood pressure,
pulse pressure, urine output, calcium levels,
and glucose levels should all be closely mon-
itored during the emergent phase of resusci-
tation. The ACCM (Brierley et al., 2009) sets
a time goal of 1 hr (“the first hour”) in the
 Article: TME200223 Date: October 23, 2013 Time: 14:42

310 Advanced Emergency Nursing Journal

ED. As noted in T.B.’s case, he was managed the absence of pulmonary edema, rales, a
in the community emergency department gallop rhythm, or hepatomegaly if initial fluid
within the first hour; however, an additional resuscitation amounts do not improve clinical
“out-of-hospital” time of 17 min during trans- findings (Brierley et al., 2009). Assessment
port must also be considered prior to defini- of the child’s lung sounds, pulse oximetry,
tive care at the pediatric tertiary care facility. heart sounds, and vital signs must be ongoing
during fluid resuscitation. A D10 isotonic
Airway Protection solution can be started at a maintenance rate
as well to prevent hypoglycemia (Brierley
Airway protection is of major importance for
et al., 2009). Historically, there have been
children with sepsis and should be rigorously
discussions whether crystalloid or colloid
monitored and maintained. In early sepsis, res-
fluid resuscitation is more advantageous. The
piratory alkalosis occurs because of centrally
timeliness of fluid resuscitation is of greatest
mediated hyperventilation. But in late sep-
importance and either solution can be used
sis, hypoxemia and metabolic acidosis occur,
as long as it is used promptly. However, one
placing the patient at high risk for respiratory
randomized controlled trial does find that
acidosis secondary to parenchymal lung dis-
although the crystalloid and colloid solutions
ease or inadequate respiratory effort, because
do not change the mortality of cases, children
of altered mental status (Brierley et al., 2009).
who receive lactated Ringers do have longer
The decision to intubate should be based on
recovery times (Ngo et al., 2001). The SSC
clinical assessment, and waiting for laboratory
(Dellinger et al., 2013) suggests the use of
findings is discouraged. As infants and young
isotonic crystalloids and/or albumin in initial
children have low functional residual capac-
fluid resuscitation. The AHA’s PALS algorithm
ity, early intubation in severe sepsis may be
(2011) suggests initial treatment only with
warranted (Dellinger et al., 2013). Up to 40%
crystalloid solution.
of cardiac output can be consumed by work
of breathing, and, therefore, intubation and
mechanical ventilation may reduce or reverse Inotropes and Vasopressor Use
septic shock (Brierley et al., 2009). Etomidate
When hemodynamic stability is not achieved
is not recommended, as the adrenal suppres-
by fluid resuscitation alone, vasopressors
sion effect could be detrimental to a pedi-
and/or inotropes should be administered. If
atric patient with sepsis (Brierley et al., 2009).
the patient is in warm septic shock (hypoten-
This differs from the adult patient with sepsis,
sive, vasodilated), norepinephrine should be
in whom etomidate’s benefits in critical air-
considered, and if the patient is in cold
way management are thought to outweigh the
septic shock (hypotensive, vasoconstricted),
adrenal suppression (Tintinalli et al., 2011b).
epinephrine should be considered (Brierley
The ACCM (Brierley et al., 2009) suggests
et al., 2009; AHA, 2011; Dellinger et al., 2013).
ketamine with pretreatment atropine and a
Dopamine can be used and titrated until clin-
benzodiazepine postintubation as the induc-
ical examination shows improvement in the
tion/sedation regimen of choice to maintain
child who remains normotensive but has per-
cardiovascular integrity.
sistent perfusion deficits (AHA, 2011). The
use of hydrocortisone, milrinone, nitroprus-
Fluid Resuscitation
side, and/or dobutamine is discussed in the
Suggested fluid resuscitation starts at 20- sepsis guidelines as adjuncts to treatment pri-
ml/kg bolus, either by intravenous push or by marily for use after admission to an intensive
rapid infusion/pressure bag, with up to three care unit, or “beyond the first hour” (Brierley
or four boluses within the first hour (Brierley et al., 2009; AHA, 2011).
et al., 2009; AHA, 2011; Dellinger et al., 2013). The AHA (2011) suggests consideration
As much as 200 ml/kg can be delivered in of central venous access for administration

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Article: TME200223
October–December 2013 r Vol. 35, No. 4
of vasopressors or inotropic medications
in the patient with sepsis. However, as a
practical matter, it may be time-consuming
and resource-intensive to establish central
access in an infant or a child during the first
critical hour in the ED. These medications
can be given peripherally until central access
is established, with frequent assessment of
the PIV site for infiltration (AHA, 2011;
Parker, 2009; Dellinger et al., 2013).
Relevance for Advanced Practice Nurses
It is important for the health care provider in
the ED to be aware of the sometimes subtle
signs of impending sepsis or septic shock. As
these guidelines are established and revised,
improvement in mortality rates has been seen
globally. In the 1980s to the 1990s, mortality
rates for pediatric septic shock were more
than 50%, but with the implementation of
such guidelines, the rate has decreased to
20%–30% (Kutko et al., 2003). There are
400,000–500,000 cases of gram-negative
sepsis in children per year globally (Kutko
et al., 2003). In another investigation, Watson
et al. (2003) found 42,364 cases of pediatric
severe sepsis per year nationally (in the
United States), or 0.56 cases per 1,000 cases
per year. Males have a significantly higher
incidence than females: 0.6 per 1,000 versus
0.52 per 1,000 cases per year (Watson et al.,
2003). The mortality rate of pediatric patients
with severe sepsis is 10.3% in the United
States (Watson et al., 2003).
Advanced practice nurses in the ED often
encounter sick children, and scrupulous ex-
amination and history taking is essential for
proper diagnosis. Rapid identification by the
triage staff can influence the outcome as well.
In T.B.’s case, his new-onset fever and singu-
lar vomiting episode may not have warranted
immediate attention, as this could have been
seen as a common viral infection that could be
treated in the outpatient setting. The impor-
tance of the initial visual assessment by utiliza-
tion of the PAT was demonstrated in this case.
T.B.’s initial abnormal appearance but normal
work of breathing and circulation to the skin
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Date: October 23, 2013 Time: 14:42
Pediatric Sepsis 311
indicated a central nervous system/metabolic
dysfunction. The associated management pri-
orities included supplemental oxygen, mea-
surement of pulse oximetry, glucose, and
other laboratory and radiographic evalua-
tions while considering possible etiologies
(Dieckmann, Brownstein, & Gausche-Hall,
2010). There is also the importance of elapsed
time in pediatric patients. T.B. was able to
compensate metabolically for quite awhile,
but his condition quickly declined shortly af-
ter his arrival in the ED. As the aforemen-
tioned evidence-based guidelines strongly
suggest, if a suspicion of sepsis is part of an
advanced practice nurse’s differential, empir-
ical therapy, with aggressive resuscitation ef-
forts, is warranted until otherwise ruled out or
contraindicated.
Critique of the ED Care
The ED care provided closely follows the SSC
(Dellinger et al., 2013), ACCM (Brierley et al.,
2009), and AHA PALS (2011) guidelines as de-
scribed previously. Aggressive fluid resuscita-
tion was conducted, ketamine was used for
intubation, and broad-spectrum antibiotic
therapy was started immediately following
collection of blood cultures. Perfusion was re-
stored and vascular stability was maintained
without the need for titrated inotropes, al-
though atropine was required initially. In
this small community hospital, time to defini-
tive care was a priority. A complete pedi-
atric sepsis workup also includes a lumbar
puncture (LP) for analysis of cerebrospinal
fluid. The priority in this case was expedi-
tious transfer to a tertiary care facility and
the LP was deferred. The diagnostic stud-
ies point to a likely abdominal etiology for
T.B.’s condition; however, bacterial meningi-
tis remained a part of the differential diag-
noses. Empirical antibiotic therapy and stabi-
lization interventions were already initiated,
and the results of the LP would not have
affected the immediate treatment plan. This
fact was important to the care during trans-
port of T.B. when droplet isolation was indi-
cated until bacterial meningitis was ruled out.
 Article: TME200223 Date: October 23, 2013
312
Additional diagnostic tests indicated by T.B.’s
presentation include a fecal occult blood test,
serum lactate, and arterial or venous blood
gas analysis. In some institutions, the lac-
tate level can be drawn as a “point-of-care”
test, which may have been useful in this
case.
Access to Care
The ED setting described previously was a
small community hospital in an urban area
where access to care was limited. Although
T.B.’s mother was uninsured, the state’s de-
partment of health care and family services
provides medical insurance to all children in
this state as universal access to emergency
medical care. A medical record review re-
vealed that T.B. had been seen in this ED
three times since his birth for primary care
treatment including vaccines and otitis me-
dia. With each prior visit, a referral to a pedi-
atrician was given, but the mother stated that
she did not follow up with the pediatrician
because there was a 3-month waiting list for
annual checkups. She explained that the com-
munity ED was nearby and always accessible
and that she knew that she would not receive
a bill for his medical care.
Maltreatment Considerations
The immediate general impression of the pa-
tient was that he appeared poorly cared for as
evidenced by soiled clothes and lack of clean-
liness. The mother’s indifference to the situ-
ation at the time of arrival was an additional
concern to the ED staff. As T.B.’s condition
rapidly declined, his mother’s coping mecha-
nism began to emerge as denial. When placing
the first PIV catheter, the mother stepped out
of the room and said, “I can’t watch this.”
She placed a chair outside the door and sat
down. A nurse sat with the mother and ex-
plained the treatment while encouraging her
to return to the room and comfort the child.
The mother declined. The mother’s affect was
flat throughout the time spent in the ED. Dur-
ing cardiopulmonary resuscitation efforts, the
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Time: 14:42
Advanced Emergency Nursing Journal
mother asked, “So should I get him a flu shot
next year?” Multiple personnel attempted to
convey the seriousness of the situation, but
the mother did not appear to comprehend.
After the patient was safely transported to
the awaiting hospital, the medical staff held
an informational debriefing. At that time, it
was determined that the boy’s appearance
and physical condition were not congruent
with the history given by the mother. On the
basis of these findings and the mother’s affect
during the event, it was decided to initiate a
report to the state’s department of children
and family services.
PATIENT SUMMARY AND CONCLUSION
The patient presented with clinical man-
ifestations of sepsis, as well as a case of
suspected child maltreatment (neglect). This
case study displayed the signs and symp-
toms consistent with septic shock. The
importance of thorough history taking and
judicious physical assessment with rapid,
definitive care were especially important in
this case. The application of evidence-based
guidelines is imperative in the management
of pediatric patients presenting with sepsis.
REFERENCES
American Heart Association. (2011). Recognition of
shock; treatment of shock. In Pediatric Advanced
Life Support, (pp. 69–107). Dallas TX: Author.
Brierley, J., Carcillo, J. A., Choong, K., Cornell, T.,
Decaen, A., Deymann, A., . . . Zuckerberg, A. (2009).
Clinical practice parameters for hemodynamic sup-
port of pediatric and neonatal septic shock: 2007
update from the American College of Critical Care
Medicine. Critical Care Medicine, 37, 666–688.
Broselow/Hinkle Pediatric Emergency System. (1993).
Patent No. R7331I-010494. Lincolnshire, IL: Vital
Signs, Inc.
Dellinger, R. P., Levy, M. M., Rhodes, A., Annane, D.,
Gerlach, H., Opal, S. M., . . . Moreno, R. [World Fed-
eration of Societies of Intensive and Critical Care
Medicine]. (2013). Surviving sepsis campaign: Inter-
national guidelines for management of severe sepsis
and septic shock: 2012. Critical Care Medicine, 41,
580–637.
Dieckmann, R. A., Brownstein, D., & Gausche-Hall, M.
(2010). The pediatric assessment triangle: A novel
 Article: TME200223 Date: October 23, 2013
October–December 2013 r Vol. 35, No. 4
approach for the rapid evaluation of children. Pedi-
atric Emergency Care, 26, 312–315.
Gilboy, N., Tanabe, T., Travers, D., & Rosenau, A. M.
(2012). Emergency severity index (ESI): A triage
tool for emergency department care, Version 4. Im-
plementation handbook 2012 edition. Rockville,
MD: Agency for Healthcare Research and Quality.
Kutko, M. C., Calarco, M. P., Flaherty, M. B., Helmrich,
R. F., Ushay, H. M., Pon, S. &, . . . Greenwald, B. M.
(2003). Mortality rates in pediatric septic shock with
and without multiple organ system failure. Pediatric
Critical Care Medicine, 4, 333–337.
Ngo, N. T., Cao, X. T., Kneen, R., Willis, B., Nguyen,
V. M., Nguyen, T. Q., . . . Farrar, J. (2001). Acute man-
agement of dengue shock syndrome: A randomized
double-blind comparison of 4 intravenous fluid reg-
imens in the first hour. Clinical Infectious Disease,
32, 204–213
Parker, M. M. (2009). Pediatric sepsis: Time is of
the essence. Critical Care Medicine, 37, 785–
786.
Serwint, J., Dias, M., Chang, H., Sharkey, M., & Walker,
A. (2005). Outcomes of febrile children presumed
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Time: 14:42
Pediatric Sepsis 313
to be immunocompetent who present with leukope-
nia or neutropenia to an ambulatory setting. Clinical
Pediatrics, 44, 593–600.
Teasdale, G., & Jennett, B. (1974). Assessment of
coma and impaired consciousness. A practical scale.
Lancet, 2, 81–84.
Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D. M., &
Meckler, G. D. (2011a). Acute abdominal pain
in children. In A. B. Kharbanda, & R. D.
Sawaya (Eds.), Emergency medicine: A comprehen-
sive study guide (pp. 839–848). Columbus, OH:
McGraw-Hill.
Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D. M., &
Meckler, G. D. (2011b). Sepsis in children. In
J. Jui (Ed.), Emergency medicine: A compre-
hensive study guide (p. 1008). Columbus, OH:
McGraw-Hill.
Watson, R. S., Carcillo, J. A., Linde-Zwirble, W. T.,
Clermont, G., Lidicker, J., & Angus, D. C.
(2003). The epidemiology of severe sepsis in chil-
dren in the United States. American Journal of
Respiratory and Critical Care Medicine, 167,
695–701.