The pediatric ward scared me the most back in medical school. After a five-year combined residency in pediatrics and emergency medicine and 15 years of practice, I still have a healthy fear of missing a dangerous pediatric diagnosis, especially sepsis.
Hardwiring a pediatric sepsis protocol for the emergency department can help but is challenging. Protocols can help clinicians, but a poorly constructed one may lack sensitivity (miss the diagnosis) or specificity (trigger too many unnecessary sepsis workups).
Almost 7,000 of the 75,000 children who develop severe sepsis in the United States die each year. That's more than 200 a day, and the number is increasing by eight percent every year. (Sepsis Alliance, Dec. 13, 2017; http://bit.ly/2vwgn0j.) Diagnosing pediatric sepsis is problematic because EPs are charged with finding the one child with a life-threatening infection in a sea of kids with the sniffles, but a pediatric sepsis screening protocol with six rules can help.
Rule 1: Don't Take the Assessment Out of the Protocol
An astute clinician conducting a focused assessment with finite objectives is required to identify pediatric sepsis. Reliance on the mere presence or absence of SIRS will lead to over- and underdiagnosis. Almost every child presenting to the ED with a relatively harmless viral URI, for example, will have SIRS, prompting overutilization of ED resources to rule out a serious bacterial infection.
Identifying pediatric sepsis at triage requires a rapid medical evaluation with special attention to a child's mental status, skin perfusion, and risk factors, in addition to the vital signs that suggest the presence of an infection. Combining SIRS with additional clinical indicators for sepsis will improve the specificity and sensitivity needed to identify needles in a pediatric sepsis haystack.
Rule 2: Always Listen to the Parents
Pediatric patients can hide serious disease. The old adage, “Pediatric patients are not little adults,” rings true. Developmentally, infants and young children can't effectively communicate, and clinicians must rely on parents with varying capability in identifying concerning symptoms. Obtaining a thorough history and identifying the presence of high-risk conditions require time to speak with the parents. Experienced parents know when their child is unwell; inexperienced parents need to be questioned thoroughly to make sure subtle historical items are not missed.
Rule 3: All Pediatric Sepsis Screens Need Reliable Vitals
Current pediatric triage standards require taking rectal temperatures in infants who cannot provide an oral reading. I wish I had a dime for every neonate who did not have a rectal temperature at triage. Don't let anyone tell you different: Insist on taking the rectal temperature when necessary to obtain an accurate temperature. Clinicians should also rely on validly measured temperatures obtained at home, even if the rectal temperature at triage doesn't trigger a fever workup.
Rule 4: Anchoring Causes Misdiagnosis in Peds Sepsis
Febrile kids need to be fully examined. This seems obvious, but it is not uncommon for parents to steer you in the wrong direction. A crying 6-month-old girl with a fever of 38.1°C and URI symptoms can still have appendicitis, a volvulus, cellulitis, or a UTI. Anchoring onto the symptoms that only a parent notices is the common basis for malpractice claims.
Rule 5: Repeat the Vitals, Repeat the Vitals
Reassessing patients gives EPs a second chance to identify a serious infection. This becomes particularly important in pediatric patients because a serious infection can begin with subtle findings and result in abrupt clinical deterioration shortly after. The classic pediatric sepsis presentation involves a young child with normal blood pressure and tachycardia. Without noticing the hypoperfused state of a preseptic child during the first exam, a second evaluation allows EPs to pick up signs of gradual deterioration and initiate aggressive management to avoid the sudden crash of pediatric septic shock.
Rule 6: Expedite Admissions to the Peds Floor and ICU
Even when the correct diagnosis and disposition have been made, a medicolegal risk remains if the next steps are delayed: the pediatrician fails to promptly evaluate the patient and get a peds or ICU bed, causing prolonged ED boarding. A pediatric sepsis protocol should include pathways for prompt disposition and care by the inpatient team.