Skip to 0 minutes and 1 secondThis is a classic case of empyema basically that side of the chest where you couldn’t hear any noises was because it had pus in it. This patient is a big sick patient and it’s really important that you recognise that and your priority is getting them to hospital as quickly as you can possibly can. Pus in the chest can lead to sepsis in children and the septic picture in this situation is one of warm shock. Now in warm shock you get vasodilatation of the peripheries. The patient’s can have what feel like quite bounding pulses, they’ll also have a really brisk capillary refill and people can get confused by that into thinking that the patient isn’t shocked.
Skip to 0 minutes and 39 secondsWe think of shocked patients as being pale, cold and clammy around the edges, prolonged capillary refill, but in the situation of a warm shock then that’s not often what you see and the big worry with these patients is that they can fall off their perch really quickly. One minute they could be looking not too bad and then the next you’re chasing your tail trying to push fluids etc into them.
Skip to 0 minutes and 59 secondsWhen this child gets to hospital, they’re going to need some work doing, they’re going to need to be given fluids, they’ll probably need inotropes to support their blood pressure and their going to need someone to get the pus out of their chest because in certain situations until you remove that, you’re not going to get on top of the infection, so for the crew, I’ve said already that the priority is to get to the hospital, if the child is in a difficult or in a bad way, then that child’s going to need fluid on the way, but giving that fluid shouldn’t be delaying you to get to the hospital.
Skip to 1 minute and 28 secondsOk get some access, get some fluid going, get to the hospital and pre alert that you got a patient coming in who you believe is in septic shock and in this case related to pus in the chest. This is the same picture you can see in the initial stages of things like meningococcal disease and the management priorities would be the same. The importance of this presentation though was to just say; “don’t get distracted”, you know there was wheeze in the chest and people like to go, “Right!
Skip to 1 minute and 51 secondsI’ve got wheeze and this must be the cause of my problem”… and actually if you look at that and focus on the wheeze, you miss the big thing which is the fact that this patient is septic. Warm septic shock shouldn’t be missed, the clues are there, just don’t let yourself get distracted.
So in this topic we have seen Marley who presented with breathing problems.
As the scenario unfolded it became clear that there was more to this case than a simple chest infection; in fact Marley had an empyema which is a condition where there is pus in the chest. Children with empyema can be really septic requiring significant levels of resuscitation (I have personally dealt with several seriously ill kids with empyema and it can be a challenge).
The whole point of this scenario though was not about reaching the actual diagnosis, rather recognising that Marley fell into the ‘big sick’ category and knowing what initial interventions would be appropriate. Knowing that there is pus in the chest is irrelevant in the pre hospital phase as you’re not going to try to get it out. What Marley needed was oxygen and fluids and rapid transfer to hospital.
The baseline skills you need to be able to spot the child who is in imminent danger of falling off their perch, is a clear understanding of the normal parameters of HR etc at different ages, and ability to perform a swift but detailed ABCDE assessment. You need to recognise the abnormal and deal with serious concerns as you meet them and in that way you will give the child the best chance of recovery. Rapid recognition of the seriously ill child is vital.