Pediatric sepsis is a low-frequency, high impact condition. Nurses and physicians do not see it often, but must recognize and treat children with sepsis efficiently when they present. This makes pediatric sepsis education particularly amenable to simulation scenarios.
Physical examination revealed inflamed gingiva, ulceration, and soft tissue necrosis (Image 1) along with mandibular lymphadenopathy (not shown). Given her symptoms, poor oral care, and her immunocompromised state, she was given a diagnosis of Acute Necrotizing Ulcerative Gingivitis (ANUG) or Vincent’s Angina.
Her physical exam was significant for bilateral tonsillar exudates, cervical lymphadenopathy, and a morbilliform rash that included the palms (Figure 1-4). Laboratory testing was significant for white blood cell (WBC) count of 16.5 thous/mcl with an elevation in absolute lymphocytes of > 10 thous/mcl. The monospot and EBV (Epstein-Barr virus) panel were positive.
The patient was in mild distress, afebrile, with stable vital signs. His physical exam revealed an erythematous, grouped vesicular rash in various stages of progression including erythematous papules, clear vesicles, and pustular vesicles. Few lesions were scabbed over. No signs of crusting or scarring were appreciated. The distribution encompassed the entire left T4 dermatome both posteriorly and anteriorly. No other rashes were appreciated elsewhere on the body.
In the long axis video, the appendix appears as an enlarged, non-compressible, blind-ending tubular structure (white arrow) with distinct appendiceal wall layers and lack of peristalsis. In the short axis video, the appendix appears as a target sign (yellow arrow) between the abdominal and psoas muscles. The maximal outer diameter (MOD) measures 11.8mm and the appendix wall measures 0.17mm. There is trace adjacent free fluid and echogenic periappendiceal fat. Transverse axis video and image (red arrow) demonstrate that the appendix is not compressible. These findings are consistent with acute appendicitis.
Neutropenia is a common oncologic emergency, and it frequently develops as a result of myelosuppression from chemotherapy. Neutropenia is defined as absolute neutrophil count (ANC) <1000/mm3, with severe neutropenia being defined as ANC<500/mm3. Patients with fever and neutropenia should be presumed to have infectious etiology and started on antibiotics immediately. The 48-hour mortality associated with an untreated infection is 20%-50%.