You are called to the surgical ward as an emergency to see an 8 year old boy who

underwent an uncomplicated appendicectomy 2 days ago. He has had increasing

abdominal pain, fever and tachycardia for 6 hours and has received 20 ml/kg normal
saline fluid bolus during that time.

A full blood count performed 1 hour ago: Hb 110; Plts 104WCC 2.2 (33% neutrophils,
35% bands)

On examination he is difficult to rouse, flushed and has a temperature of 39°C. Heart rate
186 beats per minute, blood pressure 68/29, respiratory rate 30 breaths per minute.
Abdomen distended with no bowel sounds. Extremely tender around wound

Briefly describe your initial approach and treatment.

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1. This is a medical emergency

2. I am concerned that this child has:

a. Septic shock
b. The likely source being abdominal wound infection with abscess formation
c. This child needs urgent fluid resuscitation and stabilization
d. Urgent surgical wound exploration, washout and debridement

3. Therefore my initial management includes simultaneous assessment, monitoring and

resuscitation
a. Assess airway: will need intubation (ketamine and rocuronium); RSI
b. Assess breathing: ventilate with 100% oxygen; ensure good air entry
bilaterally and exclude endobronchial intubation; secure the tube
c. Assess circulation:
i. Reassess HR, BP and perfusion
ii. Ensure x2 large bore IV access
iii. Fluid resuscitate with 20mls/kg 0.9% NaCl and repeat and reassess
iv. Start dobutamine peripherally at 10mcg/kg/min
d. Source control
i. Send blood for FBC, U&E, coagulation, gas, culture
ii. IV amoxil, gentamicin and metronidazole
iii. Surgical exploration
e. Nil by mouth
i. Nasogastric tube on free drainage

4. As per Surviving Sepsis Guidelines

a. Fluid resuscitation
b. Inotropes
c. Vasopressors
 d. Sedation and analgesia
e. Sodium bicarbonate if acidotic <7.2
f. Maintain Hb>7g/L
g. Glycaemic control
h. Ventilate at 6mls/kg
i. CVVH if oliguria, fluid overload
j. TED stockings

5. Other
a. If delay in theatre then move to PICU
b. Inform anesthetist of condition and resuscitation so far
c. CXR to confirm ETT placement
d. CVL and arterial lines
e. Inform family of developments