Case presentation for regional Paediatric meeting - presents a case of critically ill 16 month old boy with sepsis. Case and case discussion presents the successful resuscitation of critically ill Paediatric patient, highlighting the associated challenges with being in a peripheral hospital setting.

1. Paediatric Resuscitation –
the Peripheral hospital ED
perspective:
Dr Bishan Rajapakse, FACEM, PhD, MBChB
Emergency Physician, Shellharbour Hospital
Honorary Clinical Lecturer, UOW
Thinking on your feet, and living by
the skin of your teeth
Pop in Paediatrics
The Wollongong Hospital
Monday 7th Dec 2020

2. Overview
• Shellharbour ED context
• Case presentation and discussion of 16 month old patient
• Paeds resus in peripheral hospital
• Challenges / Practical realities / Interim and future
solutions
• Regional Paediatric Education Strategies with impact

3. My Background /
Perspective
• Emergency Physician Shellharbour
• Portfolio
• Medical Education / UOW Medical
students
• Research / Educational Research &
Simulation
• Wellbeing & Culture Change
• Keen on Kindness
• Wellbeing Research

4. Shellharbour Hospital:
Peripheral Hospital ED
Emergency Department
- 2 resus beds
- 12 Acute Adults+ 2 Acute Paeds
- 5 Subacute treatment spaces
Inpatient Service
- 87 Medical, Surgical and specialty beds
- Close observation Unit (9 beds)
- General Medicine
- Geriatric Medicine
- Surgical (8 Bed day care)
- 69 Mental Health beds
- NO Paeds /OBGYN
Presentations
30,000 presentations/year
6000 Paediatric presentations

5. Medical Staffing Shellharbour Hospital (for
Paeds presentation)
ED (AM/PM/Night)
• FACEM Cover 0800 – 2400 (Day/Evening)
• 2-3 ED doctors per shift (non consultant)
Paediatrics
• ED Paeds treatment (2 beds )
• Wollongong Hospital admission via paediatric
registrar
• Paediatrician on call can review patient at
SHH (30mins away)
• Vision for Life -> NETS
Anaesthetics (M-F elective lists only)
• No anaesthetics on call
• Will help out if needed between cases

6. Paeds Presentations to SHH (20% of total)
• SHH ED -30,000 total annual
presentations
• 20% (5100/25,000) of Pts are
paediatric (<16years)
• 44% (2400/25,000) are acute
patients (rest Fast Track)
• 30 patients patients are
transferred to other hospitals per
month (12% of acute patients)
Based on analysis in 2019 over 10 months (Courtesy of K Ruperto & T Couttie)

7. Medical Transfer (>30% of in-patient admissions; all
paeds admissions)
ED
Psych
Gen
Med
SSH
Gen
Surg O&G Paeds
ICU
SHH
TWH (30 mins
ambulance)
Retrieval
PICU
Paeds/
Paed
Trauma
SCH (1.5 hours
ambulance)
R
e
t
r
i
e
v
a
l
Med
subspecs

8. Paeds Medical
Transfers &
Retrieval
• Patient Transport Service
• Ambulance NSW
• Medical Retrieval (NETS)
• Transfer Times
• Wollongong Hospital
• 20-30 mins; ambulance
• Sydney Children's Hospital
• 1.5 hrs via ambulance
• 30 mins via helicopter)

9. The case

10. Our patient; Mast JS, 16 months old male
PMHx -Nil
Medications - Nil Regular
Allergies – NKDA
Social Hx
- Lives with single mother and 2
older sisters
- Attends day care

11. Triage Note – Category 3 (0224)
Woke from sleep tonight vomiting. ate the same
dinner as family, well today. fever. Foot and mouth
disease last week, went back to day care yesterday.
Examination
Temp 39, No rashes no lymphadenopathy
A - Asleep but rousable
B - Chest clear, O2 sats 99% on RA
C – HR 132
D – Asleep but rousable, No neck stiffness
Abdomen soft
Anogenital area NAD
ENT - Mild pharyngitis
Initial Visit
08/10/20
Presented
0224
History
16/12 old – fevers, rhinitis, cough
1/7
Quiet during evening
Woke up with fever 2am
• Normal oral fluid intake and
fluid output
• Nil medications given at home
• Attended daycare during the
day
• No known sick contacts
• Nil PMHx, IUTD

12. Initial Visit
08/10/20 –
discharged
0401
Progress
Child noted to be drinking water well in ED
Temperature had improved to 36.7
Diagnosis
URTI
Discharged 4am, Return if symptoms worsen

13. 11 hours
later….

14. Observations on Representation
Temp 36
A – patent
B – RR 45, O2 sats 97% RA
C - HR 176, central cap refil – 5 seconds seconds, BP 80/40
D – Responding to voice
Representation
08/10/20 1539
Triage Note (Cat 2)
unwell since last night presented in this ED
and d/c this morning O/A alert, crying, irritable
mottled skin, non blanching
haemorrhagic area to right arm unable to fully
get Obs as pt. agitated, taken straight to acute
area/resus

15. Initial Assessment at Triage
Child in his mother’s arms, lethargic
Mottled
Capillary refill 5 seconds
Non-blanching lesion on right upper arm
Nb – Parental consent has been obtained for this photo to be used for educational purposes

16. Logistics and our ED Context at
time of presentation
• Space = Bad
• Our ED was bed blocked
• 2 Resus beds full
• All acute & 2 paediatric beds full
• Staffing = Good
• Cross over tome between morning and evening shifts
The 2 resus beds were full
• Other Factors
• Infection control (febrile child in covid times)
• Mother also had a 5 year old child with her and
another child in the waiting room. Single mother

17. Representation Hx 08/10/20 1540
History
16/12 old , last well 10/7 prior
Unwell with hand, foot & mouth disease for 7 days
Cleared GP to return to daycare 2/7 prior to ED presentations
First day back at daycare yesterday 1/7 prior
• Ate dinner and slept
• Awoke 2330, unusual cry, fever at 0200hrs
• Presented to ED 2:30am, fever settled, tolerating fluids,
• d/c home with representation advice

18. Representation Hx 08/10/20 1540
After getting home from ED patient
- off his food,
- dozing on and off for the whole day,
- mother again noted a weaker than usual cry
• RASH noted rash on his upper arm and his abdomen this
afternoon
• Decided to represent as patient was having difficulty walking
Last paracetamol 2 hours prior to presentation

19. Representation Ex - 08/10/20
1540
Examination
General - looks unwell, lethargic, mottled, whinging, lying on mum
A – Patent
B – Good air entry , Chest clear, nil creps or wheeze
C - Cap refill 5 seconds centrally, tongue moist
D – Lethargic, responding to verbal stimulation
Rash: Purple non-blanching rash approx. 4cSparse non blanching
purple lesions 1-2mm in diameter on the lower abdomen and
noted on scrotum and buttock cleft
x 2cm in the right upper medial arm
Abdomen soft non tender, nil palpable masses
ENT - Crusty rhinorhea on nares bilaterally, Ears & Throat NAD
Chest good air entry bilaterally, nil creps, nil wheeze

20. Working diagnosis
& Management
plan?

21. Our Working Diagnosis
Meningococcal Septicaemia with associated
septic shock
Invasive Meningococcal Disease (IMD)
- 30-50% of patients present with meningitis without
bacteraemia
- 40% with combination of bacteraemia and meningitis
- 7-10% with bacteraemia only

22. Initial Treatment
Patient moved to resus
2 x 22G IVC inserted into cubital
fossae
2 x sets of blood cultures taken
Ceftriaxone 50mg/kg
administered
Dexamethasone 0.15mg/kg
given
10mls/kg saline bolus x 2 given

23. Initial VBGs

24. Working
Disposition?

25. Progress and
involvement of
NETS
• Patient look sick from outset; RED FLAGs
• Suspicion of invasive meningococcal disease
(IMD)
• Duration of symptoms]
• In Septic shock; Hypotensive, tachycardic,
and biochemical marker of severe sepsis
(with lactic acidosis)
• Called Paediatrician (TWH)
• In alignment with plan already instituted -
IV Ceftriaxone 50mg/kg, and 10+10mls/kg
NS fluid bolus
• Suggested broadening the antibiotic
spectrum to include IV Vancomycin
• Activated NETS as no response to initial fluids
and Red flags
• After describing the case – sent NETS team
via helicopter

26. Vision for Life
• Collaborative discussion with NETS – agreed with
recognition likely meningococcal sepsis with potential for
cardiovascular collapse, and multi-organ failure
• Confirmed immediate dispatch of retrieval team via
helicopter (ETA 30 mins)
• NETS advised early intubation in anticipation of imminent
cardiovascular collapse due to severe septic shock
• Decision to proceed with ED staff +/- Anaesthetics if contactable
• Advised also initiate adrenaline infusion prior to this as BP
could easily drop

27. Re-Cap
Patient: 16 month old male
Working Diagnosis: Meningococcal
Septicaemia with severe septic shock
Treatment: Crystalloid boluses x 2,
ceftriaxone, dexamethasone, vancomycin,
gentamicin
Current Plan: Early ionotropic support and
intubation
Disposition: PICU Sydney children's
hospital, NETS team via helicopter
activated (will arrive in 30mins)

28. In the resus
room…
• Patient + Mother/Grandmother
• Existing Resus TEAM
• Evening FACEM (Team Leader)
• Registrar ED Advanced Trainee (primary survey
• Resus nurse and Paeds nurse
• Medical student
In rest of Emergency Department
• Acute area – Day FACEM, senior and junior
doctors (cross over time)
• FAST track –Doctors x1, Nurse practitioner ,
Nursing staff

29. Assembling
our
Intubation
Team
• 2 FACEMs
• One Team Leader
• One Airway
• ACEM AT – Drugs
• Airway Nurse, Drugs, Scribe
• Social Worker – notified to be present
• Medical student supporting the
patient psychosocially in interim

30. NETS-Calculator
Intubation drugs
• Ketamine 1-2mg/kg (20mg)
• Rocuronium 1.2mg/kg (16mg)
Iontropes
• Adrenaline 0.05-0.5 mcg/kg/min
ETT Tube size
• Cuffed Size 3.5 +/- 0.5

31. Intubation 1722 (presented 1.5 hours prior)
FACEM2 Airway/FACEM1 Team leader/ED Reg- Drugs
DSI with ketamine 12 + 8mg and rocuronium 16mg
• Direct laryngoscopy with bougie, 3.5mm cuffed tube ETT
• Good vision of ETT going through the cords
• 13cm at teeth
• CO2 trace obtained post intubation
O2 sats initially 99% however within 30 seconds started dropping

32. Initial Intubation - 1722
Tube was suctioned , nil improvement in sats
• ETT removed
• Rescue LMA size 2 inserted , O2 sats improved back to 90- 100%
Discussion:
- advice from video-link team was that the patient wasn’t being
ventilated fast enough once intubated
- Possible blocked ETT from vomitus/secretions

33. Re-intubations, and tube adjustment
1. Anaesthetist arrived in the department
(1741)
• First attempt with Size 4 Cuffed ETT
• CO2 trace obtained however, perceived air
leak around tube
• Dropping O2 saturations
• ETT removed, LMA size 2 reinserted
Re intubation by Anaesthetist
• Second attempt with Size 4.5 cuffed ETT
• O2 sats 100%
• Tube secured by NETS, 15cm at the teeth
3. O2 sats dropping -
Endobronchial Intubation
suspected
Confirmed Endobronchial
intubation with CXR
Tube pulled back with cuff up,
ventilation nil problems – O2 sats
99%

36. Further progress in SHH prior to transfer
• Femoral central line – inserted by FACEM
• Social worker input for with Mother; prepared to go to SCH in helicopter
• Updated diagnosis and uncertain prognosis at this stage
• Patient continued to have borderline BP , improving pH and lactate and
transferred
• Left SHH ED at 23:05pm

37. Bloods
Blood results available after patient was transferred

38. Progress in Sydney
Children’s Hospital
(Total 8 days in ICU
and Ward)
• PICU SCH (arrived 9/10/2020)
• LP not performed due to clinical instability and
lack of meningeal symptoms
• 8/10/2020 BC Growth of Neisseria Meningitidis,
PCR positive 9/10
• Public Health notified
• ID recommended 7 days IV ceftriaxone
• TTE normal on 9/10/2020
• Improving Petichiae and R axillary skin leasion -
USS no collection
• General Ward
• Progress with Nutrition and Physio
• Nil neurological deficit detected in walking
and feeding
• D/c 17/10/2020
• Script for Cephalexin 5/7 for erythematous lesion
R axilla

39. A Good Outcome
• Note from physiotherapist after discharge
20/10/20
(Mum) reports she feels (patient) has
returned to his pre-illness GM skill level .
He is running climbing stairs and his balance
appears fine and that their GP saw (patient)
yesterday and was of the opinion he did not
need physio F/U .
Emergency Physician SHH – contacted
mother for telephone follow up (1 month
later)
• Master JS was doing well – very grateful
for care by all staff in SHH and NETS
• Told in SCH hospital that good care may
have saved her son’s life

40. Acknowledgement &
Thanks to our TEAMs
– ie all staff involved
in care of patient
across the district

41. Points for
Discussion
• Meningococcal sepsis ; Rare but important
condition to treat expediently
• Desaturation post intubation
• Ventilation in Paediatric patients - Ambu
bag
• Cuff Leak
• Complexity of high level paediatric
resuscitation in peripheral ED
• Organizing a resus team
• Challenges of paediatric intubation
• Availability of anaesthetist
• Necessity for time critical helicopter
transfer to PICU

42. Incidence of Meningococcal Disease

43. Incidence by Age for 2019

44. Thompson et al (2006)– “Clinical recognition of meningococcal disease in
children and adolescents” - Lancet
“Few infections can cause the
tremendous stress that occurs
when meningococcal disease
enters a community.”
“The rapid onset of disease, the
fulminant course of some infected
patients, and the mortality and
morbidity are all reasons why this
infection is so dreaded.”
• Importance of early recognition

45. 0-8 hours Nonspecific symptoms
>9 hours more classical symptoms

47. Potential
factors that
impacted on
desaturation
post
intubation
Right Main Bronchus intubation
Air leak around cuff
Suboptimal ventilation
During preoxygenation due to
mask and ambu-bag (release
valve)
Post intubation – due to
hypoventilation (low rate)
Other factors…

48. ANZCOR : Introduction to
Paediatric Advanced Life
Support Techniques
in Paediatric Advanced
Life Support
With cuffed tubes, a size 3.5 mm for children
1-2 years of age and for older children
according to the formula age (years)/4 + 3.5
mm.
Irrespective of formulae, the correct size
should enable adequate lung inflation with
escape of a small volume of gas around the
tube on application of moderate pressure.
However, cuffed tubes or closer fitting
uncuffed tubes may be preferable when lung
compliance is poor. Initial insertion of a cuffed
tube obviates the need to change a tube
when oxygenation is compromised by a leak
around a tube which is too small.

49. Paediatric patient who needs intubation
/ionotropes in Peripheral hospital setting
Challenges to patient
• Low frequency presentation
• Onsite critical care FACEMs;
• Backup via NETS
• Variable availability of Acute
Anaesthetic back up
• No onsite ICU or Paeds ICU
• Retrieval at best 30 mins away
(usually 1-2 hours or more)’
Challenges to Department (Emergency)
• FACEM resources tied up for
several hours to one patient (in
this case 3 hours continuously)
• Impact on other Acute patients
in ED

50. Potential solutions to Resource limitations
For the Patient
Early involvement of Pediatrician
• In person, over phone advice
Early Involvement of NETS
Phone a FACEM friend (Paeds dual trained)
Involve social worker to address psychosocial
needs of parents
For Department
• Involve on call FACEM staff
• Involve ED Director
• Involve DMS
Extra staffing / RE-allocate staff

51. Gratitude for
Regional
Paeds
Education
strategies!
• Strategic Education
• Insitu Simulation of Paeds
cases
• Regional Sim training
• Regional Case discussion
education sessions (Pop in
Paeds – montly meeting)
• APLS courses
• Support Champion educators
• Liason specialist paediatric
staff
• Paediatric CNC
• Dual Trained FACEMs (Paeds
/ED)
• Scope for More?
• Closing the feedback
loops for good
care/areas to improve
(to all staff)
• Other knowledge
translation strategies
• Regular Paeds
contact
• Online Education
• Clinical decision
aids / Web/ smart
phone based

52. Paediatric
Education across
the region has
many faces, and
always creates a
smile
Shellharbour ED FACEMs and ED Nursing staff post Resus for Kids training update

53. Summary
of Key
Points
• Meningococcal sepsis is rare but important
condition to recognize early and treat
• Paediatric Resus is challenging in the context of
the peripheral hospital ED setting (lack of
onsite critical care & Paeds inpatient services)
• Strategic regional Paediatric education
including SIM/case discussion/championship is
an investment that is worth the effort!

54. Thank you !

55. Acknowledgements
Support with presentation & clinical care
• Dr Michael Culshaw - FACEM ISLHD & Tracie Couttie - Paediatric Nurse
Consultant
• Dr Shalini Cleophas – FACEM ISLHD
• Dr Jane Friedrich (ACEM advanced Trainee Registrar)
• Entir Shellharbour ED staff (Nurse in Charge , Resus Staff, also UOW Med
student Eyra Muzner)
• Wollongong Paediatrics Department
• Wollongong Anaesthetics Department
• NETS & Sydney Children’s Hospital ICU