Patient Care

Recognizing Pediatric Sepsis with CHART Mnemonic

Issue 9 and Volume 41.

Six million children die from sepsis worldwide every year, making it the leading cause of morbidity and mortality in children.1

In the United States, almost 50,000 cases of severe sepsis occur in pediatric patients (age 0–19 years old) annually, increasing approximately 13% per year (81% total rise) since 1995.2,3 Of these cases, an estimated 4,400 children die annually, with infants the most susceptible age group as well as the age group in whom sepsis is most severe.2,4

The good news is that, while the incidence of severe sepsis among pediatric patients is rising, the fatality rate among those who receive treatment for sepsis has fallen from 10.3% to 8.9% in the same time frame.3 This means that although we’re likely encountering sepsis in pediatric patients more often than we recognize, if these smallest, sickest patients can be identified and receive the care they need, there’s a better chance they’ll have a positive outcome.

The Challenge We Face

The low frequency of pediatric patient encounters combined with increased fragility of septic patients creates a recipe for one of the biggest challenges any healthcare provider can face.

To compound the problem, the severity of septic shock is often masked in infants and children due to their strong compensatory mechanisms. Because of this, the progression from simply ill to severely sick to organ failure may appear to happen very suddenly.5

If sepsis can be identified early, when not yet obvious, the treatment is often simple and recovery is much more likely. However, if sepsis progresses until the shock is obvious, it’ll be much more difficult to bring the patient to recovery. This is why it’s crucial for EMS—healthcare providers with the first patient contact—to remain alert for the clinical indicators of sepsis in pediatric patients, and to know what to do when they find them.6

In adults, sepsis occurs when a pathogen (e.g., virus, bacteria, fungus or parasite) triggers a dysfunction of the immune system, causing systemic inflammatory response syndrome (SIRS). When this immune system dysfunction occurs, it results in a cascade of physiological immune, inflammatory and circulatory changes including vasodilation (causing distributive shock), capillary leakage (causing hypovolemic shock), and increased clotting that results in many smaller blood vessels being blocked by clots (causing obstructive shock) all at the same time.7

Although the pediatric pathophysiology is similar, it can be said that sepsis in pediatric patients is, “All that, only more so, but less obvious.”

Sepsis in pediatric patients also begins with infection, but this infection may not be immediately evident. Although the classic sign of infection in the pediatric patient is fever, many pediatric patients with severe sepsis may be found to be normothermic or even hypothermic. This is particularly true for babies, neonates and infants, and providers should beware the cold baby, remain alert and follow a complete and careful assessment process.8

The initial presentation of sepsis in pediatrics is often nonspecific, especially in younger patients.9 Compounding this problem is that as sepsis progresses, subtle changes in vital signs can be difficult for providers to recognize.

Reference devices such as charts, tapes, wheels and smartphone apps must often be used to check the patient’s vital signs against age-appropriate ranges for pulse rate, respiratory rate, blood pressure, etc.

If these early subtle changes aren’t assessed to be perceived as a clinical picture of septic shock, the disease may progress to multi-organ dysfunction syndrome (MODS), where the acuity becomes obvious as the patient begins a rapid and possibly irreversible cardiovascular collapse.

Follow the Patient’s CHART

So how do you tell the difference between a pediatric patient with sepsis and a kid who just has the sniffles? What do you ask? What do you look for? What’s the correct treatment? What’s an EMS provider to do?

When you encounter a pediatric patient with a known infection or who’s “sick” for a reason that’s yet undetermined, the answer is to carefully follow the patient’s CHART: complaint, history, assessment, red flags and treatment. This simple mnemonic will guide you through the identification, assessment and treatment of the pediatric sepsis patient in a way that’s adaptable to any level of EMS provider in any system.

Complaints: What Was EMS Called For?

Common initial pediatric patient complaints for which EMS is called that cause an EMS provider to begin to think “sepsis” include infections, such as ear, respiratory or urinary tract.

Another primary complaint associated with sepsis is a blotching, non-blanching rash (purpura fulminaris) that can be identified by gently pressing a clear glass against the skin to see if the rash blanches or disappears.

Still, sharp EMS providers won’t have to wait for the patient, their family members or caregivers to blurt out the word “infection” before considering sepsis. Keep an eye out for complaints that classically point to infection such as fever, runny nose, rash, vomiting/diarrhea, discharge or pus, or concentrated, foul-smelling urine.

An easy-to-remember collection of complaints that point to sepsis in older children and adults actually spell out the word “sepsis.” If the patient is shivering, in extreme discomfort, pale, sleepy (inappropriately so), “I feel like I might die” or short of breath, consider SEPSIS.

Keep in mind that some of your small patients might not be old enough to complain of anything. Not only can young children, especially infants and neonates, often not speak for themselves, they may only experience vague and nonspecific complaints such as extreme sleepiness, lethargy or irritability, and may have no known history or obvious (to the layperson) outward signs of infection.

In some patients the infection may not even be the chief complaint. The patient may have severe sepsis or septic shock that’s causing altered mental status, acute respiratory distress or other symptoms of shock.

The bottom line: When presented with a complaint that’s either directly connected with an infection or with a child who’s clearly sick but with no clear cause, perform a sepsis-focused history.

Recognizing Pediatric Sepsis with CHART Mnemonic
Rapid IV/IO access is important for fluid resuscitation and
medication administration. Photo Rommie L. Duckworth

History: What to Ask About

Although not every childhood infection leads to sepsis, the complaints above are an important reminder to search for special items in a pediatric patient’s medical history that will make them more susceptible to sepsis. These include anything that might decrease the patient’s immune system such as immunotherapy, chemotherapy, regular use of steroids, any B or T cell deficiency, AIDS, or any other condition, therapy or treatment that reduces the effectiveness of the immune system.10 It also includes virtually all infants < 90 days old since they don’t yet produce the antibodies to protect themselves.

Family or caregivers may consider the infection to be a secondary issue, but it’s important for EMS providers to gather as much information as they can, especially if the infection has been diagnosed or identified. The most common infections that lead to sepsis in infants include E. coli, respiratory synctial virus (RSV), and (more rarely) listeria.10

While it may be difficult to remember these, a good starting point is simply, “Has this child had any recent infections or is he/she on antibiotics?” Likewise, it’s important to find out if the patient has had regular childhood immunizations. Lack of immunizations may put the child at higher risk for infections.

EMS personnel should also ask about co-morbid factors that may lead a pediatric patient to either be more susceptible to either an infection, cardiovascular collapse (i.e., shock) or both. These include cancer, cystic fibrosis, sickle cell disease, physiological issues such as liver or splenic dysfunction, poor cardiac or respiratory reserves, and factors related to surgery including children with burns, organ transplants, indwelling devices, recent surgery/traumatic injury or so-called “technology dependent” kids.10

Neonate-specific risk factors include a history of their mother’s water breaking more than 24 hours early, premature birth, very low birth weight, and mother having group B Streptococcus, Staphylococcus aureus, or any of the of the so-called TORCH infections untreated at the time of birth. These include toxoplasmosis, “other” (e.g., syphillis, varicella-zoster, parovirus), rubella, cytomegalovirus and herpes.11

Sepsis that develops from congenital infections such as these within the first 72 hours of birth is considered early onset neonatal sepsis and is generally acquired before or during the delivery process.

Sepsis that develops after 72 hours after birth and before 28 days of life is considered late onset neonatal sepsis, the most common cause of which is Coagulase-negative staphylococci (CONS).12 Late onset neonatal sepsis usually develops from a nosocomial (hospital-acquired) or community-acquired infection.9

The bottom line: Find out if the patient has a history of known infection, or of anything that might reduce the effectiveness of the immune system, increase the chance of infection or, especially for the infants and neonates, a history of untreated infections in the mom. If the answer is probably or definitely “yes,” then it’s time to assess.

Recognizing Pediatric Sepsis with CHART Mnemonic
Although the classic sign of infection in the pediatric patient is fever, many
pediatric patients with severe sepsis may be found to be normothermic or
even hypothermic. Photo courtesy Dannie Myers

Assessment: What to Measure

When you assess the pediatric patient, it can be very easy to integrate sepsis-specific analysis. Begin, as always, with the pediatric assessment triangle to help you prioritize your patient assessment and care.13 Even if you suspect sepsis to be the primary underlying issue, be sure to consider other possibly related or unrelated treatable conditions that the patient may have, including hypoglycemia, pneumothorax or respiratory distress.

With the huge variations in how different EMS providers in different EMS systems assess patients, it can be difficult to give a “one-size-fits-all” process for suspected pediatric sepsis. Providers should always follow their local protocols, especially when it comes to the use of advanced assessment and treatment tools and techniques.

Suspect sepsis if the patient complaint raises your suspicion for sepsis and the patient history points to infection. Many assessment criteria exist to help providers evaluate a patient for SIRS. If your EMS system doesn’t already have an assessment criteria in place, consider using this modified version of the Robson criteria which, in adults, has been shown to increase EMS providers’ sensitivity to 75% vs. 12% in those attempting to identify sepsis without set criteria.14

If using this assessment criteria, you should consider sepsis or septic shock if a child has a suspected or proven infection and has at least two of the following:

>> Altered mental state:

  • Extreme or unexplained irritability, delirium, lethargy, “floppiness.”
  • AVPU = V, P or U.
  • GCS < 11 or recent change > 3.

>> Body temperature: < 97 degrees F or > 101 degrees F (< 36 degrees C or > 38.5 degrees C).

>> Tachycardia: Use a reference guide for age appropriate range.

>> Tachypnea: Use a reference guide for age appropriate range.

>> Serum glucose > 180 mg/dL.

The bottom line: Pediatric patients are very good at masking their level of distress until they reach the point of total cardiovascular collapse. Since some criteria may require a pediatric vitals reference, providers should be sure to know not only where one is in their gear, but also how to use it quickly.

An assessment revealing two or more of the criteria has been shown to be accurate in identifying pediatric patients with sepsis. In addition to treating patient care priorities as you find them, the next step is to look for red flags indicative of severe sepsis or septic shock.

Red Flags: What to Check

The complexity of severe sepsis and septic shock can be overwhelming to healthcare providers of any level, in or out of the hospital. Although many treatment guidelines rely on criteria such as white blood cell count and arterial hypoxemia, the following can be red flags can be identified easily and rapidly by ED and EMS field personnel. Note that some items may require specialized equipment, education and authorization to use.

>> Skin is pale, ashen, cyanotic or mottled, or has a non-blanching rash;

>> Prolonged capillary refill of > five seconds;

>> Supplemental oxygen required to maintain SpO2 > 92%;

>> End-tidal carbon dioxide (EtCO2) < 32 mmHg;

>> Respiratory dysfunction including severe respiratory distress, tachycardia, bradycardia, grunting or apnea;

>> Heart rate > two deviations high for age range (use reference);

>> Systolic blood pressure in the appropriate age range is:

  • < 1 month: < 60 mmHg;
  • 1 month to 10 years: < 70 + (2 × age in years) mmHg;
  • Older than 10 years: < 90 mmHg;

>> Urine output < 1 mL/kg/hr (dry diapers);

>> Serum glucose < 120 mg/dL or > 180 mg/dL;

>> Serum lactate > 4 mmol/L; or

>> Ultrasound shows inferior vena cava decreases in diameter > 50% on inspiration.

The bottom line: Many EMS systems have their own sepsis alert criteria for adults and children. You should use that criteria and follow your local guidelines for alerting hospital personnel.

If you don’t work in a system with a formal sepsis alert protocol or one that applies only to adult patients, these red flag criteria can guide you in identifying a critically ill patient. Should this occur, it’s critical that you be a patient advocate and alert receiving hospital staff prior to arrival and again face-to-face, if by no other means than by saying, “I suspect sepsis.” In the meantime, begin treatment during transport.

Treatment: What EMS Should Do

Treatment for sepsis in pediatric patients follows an ABCD format: airway, breathing, circulation, drugs.

Airway: Pediatric patients experiencing severe sepsis or septic shock may require placement of an advanced airway.15 Rapid sequence, delayed sequence or medication-facilitated intubation should be used with caution as many induction agents may precipitate cardiac arrest in pediatric patients in septic shock.8

Ketamine is the preferred induction agent as it maintains cardiovascular stability and has a neutral effect on the immune system.8,16 Providers must not use etomidate on septic pediatric patients. Etomidate may block the body’s normal stress response and increase the severity of septic illness.17

Breathing: Pediatric patients in distress will often be working very hard to breathe. This work increases the patient’s oxygen demand, which may already be high due to increased metabolism (fever) and the metabolic work to compensate for the shock state. Supportive oxygen is appropriate if the patient is in respiratory distress or is hypoxemic (i.e., SpO2 < 94%).

An appropriately sized continuous positive airway pressure (CPAP) or bag-valve mask (BVM) can be used to reduce or eliminate work of breathing for the patient. In this way you can simultaneously increase ventilatory effectiveness and reduce metabolic workload and oxygen demand.17–19

Keep in mind that aggressive ventilation is likely to decrease cardiac preload because you’re increasing pressure in the chest and decreasing blood return. Because of this, septic pediatric patients should receive concurrent treatment for their circulation along with airway and breathing management.

Circulation: Rapid vascular access via IV or intraosseous (IO) device is important for fluid resuscitation and medication administration. The recommendation for initial fluid administration is 20 mL/kg boluses of normal saline (0.9% sodium chloride) over 5–10 minutes until any of the following occur: signs/symptoms improve; rales; or hepatomegaly (enlargement of the liver-relatively easy to identify by palpation in pediatric patients).17

Although many EMS protocols recommend contacting online medical direction or stoppingfluid administration at a total of 60 mL/kg, pediatric patients with severe sepsis may eventually require fluid administration of more than 200 mL/kg.17–20 These large volumes of fluid will typically be administered along with pressors and other medications to support cardiovascular function.

Drugs: Pressor medications may be necessary following, or in conjunction with, fluid resuscitation. Although dopamine may be appropriate for adults, it shouldn’t be used in pediatric patients with septic shock. Not only do pediatric patients respond differently than adults, but different pressors are more effective depending on the type and degree of septic shock that the patient is experiencing.21,22

>> Cold shock (cool extremities, delayed capillary refill): Epinephrine 0.1–1 mcg/kg/min IV/IO infusion, titrating to effect.

>> Warm shock (warm extremities, flash capillary refill): Norepinephrine 0.1–2 mcg/kg/min IV/IO infusion, titrating to effect.

Hyperglycemia is a more common finding in septic pediatric patients, but EMS providers should check for low blood sugar and correct as necessary.16 For neonates < 45 mg/dL, administer glucose 0.5–1 g/kg IV/IO of D5%. In infants/children < 60 mg/dL, administer glucose 0.5–1 g/kg IV/IO of D10%.

Antipyretic medications such as Tylenol (acetaminophen) or Motrin (ibuprofen) may be considered in order to reduce fever if the patient is in severe discomfort or if the fever is significantly increasing metabolic demands (i.e., by causing shivering).

It’s recommended that administration of antibiotics begin within one hour of identification of sepsis.23–25 When we consider that for every hour administration of antibiotics is delayed, patient mortality increases 7%, it seems only reasonable that antibiotics should be administered as early as possible, even outside of the hospital.25,26

Although this should occur in conjunction with the collection of blood cultures, obtaining cultures shouldn’t delay the administration of antibiotics.

Unfortunately, only weak evidence exists for current treatment options for pediatric patients with sepsis. Research continues to seek the best alternatives (including alternative fluid choices, corticosteroid administration, and more) as well as the guidelines for selecting them, but the current guidelines as outlined in this article have been shown to return victims of pediatric sepsis to their normal life faster.27

The bottom line: Fluids are important frontline medications in shock, but like any medications, they must be used with caution. Pediatric patients react well to pressors, but not the same pressors that work for adults.

As in any pediatric critical care situation, watch out for and correct hypoglycemia. And finally, while few systems are equipped for EMS to administer prehospital broad-spectrum antibiotics, every EMS provider should understand the importance of their early administration and do all they can to facilitate delivery of these crucial medicines.

Make the Difference

Not every infection a child gets will lead to sepsis, but when sepsis does occur it can be a complex and deadly mixture of inflammatory, immune, and coagulation responses resulting in a combination of distributive, hypovolemic and obstructive shock pathways.

Sepsis in pediatric patients often goes unrecognized until the patient is at an extremely challenging, if not irreversible, stage of shock. Early recognition relies on a good systematic assessment and good clinical judgment rather than any one single identifying clinical marker or blood test. EMS provider assessment and judgment can be aided by clear guiding system-wide protocols or a structure such as CHART.

Consistently using the recognized assessment criteria and treatment recommendations can help EMS providers work with ED and critical care staff to identify sepsis when others might miss it, begin treatment before others may start, and make a huge difference in the lives of some of the most challenging and rewarding patients you’ll ever encounter.

References

1. Kissoon N, Carcillo JA, Espinosa V, et al. World Federation of Pediatric Intensive Care and Critical Care Societies: Global sepsis initiative. Pediatr Crit Care Med. 2011;12(5):494–503.

2. Watson RS, Carcillo JA. Scope and epidemiology of pediatric sepsis. Pediatr Crit Care Med. 2005;6(3 Suppl):S3–S5.

3. Hartman ME, Linde-Zwirble WT, Angus DC, et al. Trends in the epidemiology of pediatric severe sepsis. Pediatr Crit Care Med. 2013;14(7):686–693.

4. Ruth A, McCracken CE, Fortenberry JD, et al. Pediatric severe sepsis: Current trends and outcomes from the Pediatric Health Information Systems database. Pediatr Crit Care Med. 2014;15(9):828–838.

5. Fisher JD, Nelson DG, Beyersdorf H, et al. Clinical spectrum of shock in the pediatric emergency department. Pediatr Emerg Care. 2010;26(9):622–625.

6. Pearson GA, Ward-Platt M, Harnden A, et al. Why children die: Avoidable factors associated with child deaths. Arch Dis Child. 2011;96(10):927–31.

7. Weiss SL, Pomerantz WJ. (July 28, 2015.) Systemic inflammatory response syndrome (SIRS) and sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis. UpToDate. Retrieved July 20, 2016, from www.uptodate.com/contents/systemic-inflammatory-response-syndrome-sirs-and-sepsis-in-children-definitions-epidemiology-clinical-manifestations-and-diagnosis.

8. Plunkett A, personal communication, 2016.

9. Plunkett A, Tong J. Sepsis in children. BMJ. 2015;350:h3017.

10. Santhanam S. (Sept. 29, 2015.) Pediatric sepsis differential diagnoses. MedScape. Retrieved July 27, 2016, from http://emedicine.medscape.com/article/972559-differential.

11. Stegmann BJ, Carey JC. TORCH Infections. Toxoplasmosis, other (syphilis, varicella-zoster, parvovirus B19), rubella, cytomegalovirus (CMV), and herpes infections. Curr Womens Health Rep. 2002;2(4):253–258.

12. Vergnano S, Sharland M, Kazembe P, et al. Neonatal sepsis: An international perspective. Arch Dis Child Fetal Neonatal Ed. 2005;90(3):F220–F224.

13. Dieckmann RA, Brownstein D, Gausche-Hill M. The pediatric assessment triangle: A novel approach for the rapid evaluation of children. Pediatr Emerg Care. 2010;26(4):312–315.

14. Wallgren UM, Castrén M, Svensson AE, et al. Identification of adult septic patients in the prehospital setting: A comparison of two screening tools and clinical judgment. Eur J Emerg Med. 2014;21(4):260–265.

15. Booy R, Habibi P, Nadel S, et al. Reduction in case fatality rate from meningococcal disease associated with improved healthcare delivery. Arch Dis Child. 2001;85(5):386–390.

16. Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37(2):666–688.

17. de Caen AR, Berg MD, Chameides L, et al. Part 12: Pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S526–S542.

18. El-Wiher N, Cornell TT, Kissoon N, et al. Management and treatment guidelines for sepsis in pediatric patients. Open Inflamm J. 2011;4(Suppl 1-M11):101–109.

19. Surviving Sepsis Campaign. (April 2015.) Bundles. Retrieved July 20, 2016, from www.survivingsepsis.org/Bundles/Pages/default.aspx.

20. The UK Sepsis Trust. (2015.) Clinical toolkits. Retrieved July 20, 2016, from www.sepsistrust.org/info-for-professionals/clinical-toolkits/.

21. Brierley J, Peters M. Distinct hemodynamic patterns of septic shock at presentation to pediatric intensive care. Pediatrics. 2008;122(4):752–759.

22. Ventura AM, Shieh HH, Bousso A, et al. Double-blind prospective randomized controlled trial of dopamine versus epinephrine as first-line vasoactive drugs in pediatric septic shock. Crit Care Med. 2015;43(11):2292–2302.

23. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589–1596.

24. Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045–1053.

25. Collopy KT. (June 19, 2015.) 4 steps to prepare for prehospital antibiotic administration. EMS1. Retrieved July 20, 2016, from www.ems1.com/drugs/articles/2199302-4-steps-to-prepare-for-prehospital-antibiotic-administration/.

26. Weiss SL, Fitzgerald JC, Balamuth F, et al. Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis. Crit Care Med. 2014;42(11):2409–2417.

27. Paul R, Melendez E, Stack A, et al. Improving adherence to PALS septic shock guidelines. Pediatrics. 2014;133(5):e1358–e1366.