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A Dying duck?!

A Dying duck?!. Introduction. How the case presented Acute management Information on the Diagnosis. Case Presentation. A&E referral direct to the consultant on-call 16 year old girl “think she may be doing a bit of a dying duck”

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A Dying duck?!

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  1. A Dying duck?!

  2. Introduction • How the case presented • Acute management • Information on the Diagnosis

  3. Case Presentation • A&E referral direct to the consultant on-call • 16 year old girl • “think she may be doing a bit of a dying duck” • But some abnormal observations, so we have done some bloods (not yet back), the venous gas shows a lactate of 4.8, think it must be an error. ... Will you check her over?

  4. On the ward .... • Hx(hx from mum, but with very clear and well articulated interjections from the patient) • 1 week history of generalised lethargy, no appetite, weak • Looking pale, not her normal self • Vomiting for a few days • Intermittent temperatures (paracetamol given) • Mild generalised abdominal pain • Seen by GP (mum had to carry her to the car as she was unable to walk), told to come back tomorrow for blood tests. Mum still concerned brought to A&E • PMHx - nil, DHx - nil

  5. Examination • Very pale, lying very still then suddenly very restless, slightly grey around lips • Chest clear (RR 30), HS 1+2+0 (HR 100) • Cap refill 3 seconds, Temp 38 • Abdomen Soft, generalised tenderness, no guarding, bowel sounds present

  6. Immediate management? • A – clear (speaking) • B – Good air entry, sats 98% RA • C – Cap refill 3, tachycardic, hypotensive, pale, grey lips = Shock • IV access • Fluid Bolus, normal saline, 500ml run through • While chasing bloods asked surgeons to come and review to exclude a surgical abdomen (lactate = 4.8)

  7. Sepsis Criteria

  8. Bloods • FBC – Hb 13, WCC 14, Neut 13.5 • U&E – Na 128, K 4.1, U 8.6, Creat 258 • LFT – Bili 113, ALT 196, ALP 106 • Coag screen – INR 2.4, PT 30.1 APTT 30.9 • CRP 373 • Lactate 6.3 Diagnosis: Shock with Multi-organ failure

  9. What would you do next? • Moved to HDU bed • Blood cultures • CXR • IV antibiotics (not gentamicin) • Further history • Pregnancy – no chance as on period (uses tampons, changing some 12 hours apart) • Denies overdose • Catheter • Monitor fluid balance • Urine dip (clear) & PT (negative) • Discussions with haematology consultant on call re clotting • Discussions with paediatric renal & liver teams • FFP to be given • Warned ICU critically ill child may need a bed

  10. Source of sepsis • Excluded; UTI, abdomen, chest, ENT, endocarditis, cellulitis, encephalitis, meningitis • Dr Britland’s suspicion of Toxic Shock syndrome needed excluding • Gynae referral for examination and swabs • Vaginal Swabs came back as showing staph Aureus= Toxic Shock Syndrome

  11. Toxic Shock Syndrome • Staphylococcus aureusexotoxin • 25% of all S Aureus strains are toxigenic • 4-10% of healthy people are colonised by toxigenic strains • Releases cytokines and interleukins • (Toxic shock-like syndrome = streptococcus pyogenenes) • UK – 40 cases per year

  12. Causes of TSS 1) Related to the Female Genitourinary Tract • Barrier contraceptive use • In the puerperium • nonobstetric gynaecological surgery • Septic abortion 2) Related to Skin or Soft Tissue Infections (50%) • primary staphylococcal infections - folliculitis, cellulitis, carbuncle, muscle abscess • Staphylococcal infections of burns, bites, surgical wounds 3) Related to Respiratory Tract Infections • upper and lower 4) Related to Skeletal Infections • osteomyelitis • septic arthritis 5) Menstrual related • Tampon Use • earliest known cause of TSS, • now less than half the number of cases • 50% cases

  13. Diagnostic criteria • BMJ Best Practice • Reingold AL, Hargrett NT, et al. Toxic shock syndrome surveillance in the United States, 1980 to 1981. Ann Intern Med 1982; 96(Part 2): 875-880.

  14. Diagnosis 1) Fever: temperature ≥ 38.9 oC 2) Rash: diffuse macular erythroderma ("sunburn") 3) Hypotension: BPs ≤ 90 mm Hg (adults) or ≤ 5th percentile (children) for age, or orthostatic hypotension, dizziness or syncope 4) Multisystem dysfunction: at least three: • Gastrointestinal: vomiting, diarrhoea • Muscular:myalgia, or serum CK ≥twice normal • Mucous membranes: vaginal, oropharyngeal, or conjunctivalhyperemia • Renal: urea or creatinine ≥ twice normal • Hepatic:bilirubin or ALT ≥ twice normal • Hematologic: platelets ≤ 100,000 per L • Central nervous system: disorientation or alteration in consciousness but no focal neurological signs at a time when fever and hypotension are absent 5) Desquamation: 1 -2 weeks after the onset of illness (typically palms and soles) 6) Evidence against an alternative diagnosis: negative cultures

  15. Differential Diagnosis • Mimics common febrile illnesses • Scarlet fever, • Kawasaki syndrome • Staphylococcal scalded skin syndrome • Cellulitis • Meningococcal disease • Infectious mononucleosis • Infective endocarditis

  16. Prognosis • 2-3 deaths / year in UK • Mortality = 30-70% • May return in those who survive – not known to affect fertility in women, but need to be closely monitored post-partum. TSS is so rare that most doctors will not come across TSS during their medical career.

  17. Lessons Learnt • Missed diagnosis! • Well articulated • Vague history • Listen to the parents!!! Mum knew she was poorly all along. • If some clinical abnormalities are there – investigate them • Use your own judgment.

  18. Toxic shock syndrome in burns: diagnosis and management. Arch Dis Child EducPract Ed 2007;92:ep97-ep100 doi:10.1136/adc.2006.101030 • http://www.toxicshock.com/healthprofessionalsinfo/table1.cfm • http://bestpractice.bmj.com/best-practice/monograph/329.html

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