Case 36 A febrile boy with a scald
Calum, an 18-month-old boy, attends ED with an accidental scald to his left lower leg and foot, after kicking over a cup of tea that had been left on the floor. The wound is assessed to be less than 1%, partial thickness and noncircumferential. There are no safeguarding concerns. The wound is dressed and Calum is discharged home.
Three days later Calum is brought back to the ED as he has developed vomiting and diarrhoea. At triage he is noted to have a temperature of 38.5°C, and a heart rate of 165/min. His other observations are within normal limits including a CRT of < 2 seconds, although he does not have his BP measured. He is given a dose of paracetamol and is started on an oral fluid challenge at triage.
Calum is assessed by the ED FY2 doctor, Dr Evans, 2 hours after his arrival. He is now afebrile with a heart rate of 140/min and his other observations remain within normal limits. He has tolerated his oral fluid with no further vomiting. He is found to have a macular-papular rash, with no petechiae. The burn dressing is not removed as Calum is due to be seen by the community nurses that afternoon.
Dr Evans makes a diagnosis of viral gastroenteritis. As Calum, has tolerated his fluid challenge and the fever has settled, Dr Evans plans to discharge the patient home. He discusses this with the ED registrar, Dr Riley, although Dr Evans makes no mention of Calum’s recent burn. Dr Riley , agrees with Dr Evans’ plan, and Calum is discharged with gastroenteritis advice.
Do you think this is an appropriate diagnosis/management plan?
That afternoon, the ED receives a blue call from an ambulance, alerting the ED that they are en route with Calum, who has a fluctuating level of consciousness. A paediatric cardiac arrest call is placed and the arrest team are present when Calum arrives.
On arrival, Calum has a temperature of 39.5°C, a heart rate of 200/min with a CRT of 2 seconds peripherally, a respiratory rate of 35/min and SaO2 of 98% in 10L/min of O2. The GCS is 12–13 and the nurse is unable to obtain a BP measurement. His rash has progressed to involve the whole body. Calum’s burn is now undressed and shows a thick yellow crusting exudate.
The paediatric registrar, Dr Adwani, obtains peripheral iv access and sends base line bloods including blood cultures. A venous gas and FBC, are checked by near-patient testing in the ED. A diagnosis of sepsis is made and Calum is started on iv co-amoxiclav. Although he is tachycardic, Dr. Adwani is reassured by the normal CRT and prescribes maintenance iv fluids.
Is this a reasonable course of management?
The blood gas shows a partially compensated metabolic acidosis with a pH of 7.02 (normal 7.35–7.45), a pCO2 of 3.5 kPa (4.0–6.5 kPa) a BE of −11 mmol/L (−2.5 to +2.5 mmol/L) and a lactate of 6.4 mmol/L (<2 mmol/L). The FBC shows an Hb of 12 g/dL (11–14 g/dL), a WCC of 2.3 × 109/L (4–11 × 109/L) and platelets of 80 × 109/L (150–400 × 109/L).
Dr Adwani telephones the on-call consultant, who advises that the child is likely to have toxic shock syndrome (TSS), with warm shock and asks Dr Adwani to aggressively fluid resuscitate Calum. Dr Adwani gives 2 × 20 ml/kg boluses of 0.9% Saline, but this has no effect on Calum’s clinical condition.
At this stage the consultant arrives and confirms the clinical diagnosis of TSS. A further 20 ml/kg fluid bolus is given, while at the same time the local PICU and retrieval team are contacted. On their advice noradrenaline and dopamine infusions are started.
Calum is transferred to a PICU where he shows evidence of multi-organ system failure. Despite all possible therapies, he dies 24 hours later after developing the Adult Respiratory Distress Syndrome (ARDS) and becoming impossible to ventilate. The causative organism is confirmed as an exotoxin-producing strain of Staphlococcus aureus.
The hospital declares a serious incident and a full root cause analysis of Calum’s death is undertaken.
Expert opinion
Toxic Shock Syndrome is a form of distributive shock caused by toxins produced by Staphylococcus aureus or Group A Streptococcus [GAS]. In both cases the toxin acts as a super-antigen causing a polyclonal T cell activation and then a cytokine storm, which results in multisystem organ failure.
Although associated with tampon use, 50% of cases are caused by other types of infection, commonly skin and soft tissue infections, particularly of burns or surgical wounds. GAS infection is also associated with recent Varicella infection.
The clinical diagnosis is based on a combination of fever, rash, hypotension and evidence of organ failure in 3 or more systems. As the exotoxins cause erythroderma, the capillary refill time is an unreliable sign and it is the tachycardia and hypotension that indicate the warm shock.
Once recognized the treatment is initially aggressive fluid resuscitation, then inotropic support and support of other organ systems as needed plus combination antibiotic therapy. Most patients will need to be treated in a PICU. Staphylococcal TSS has a mortality of 3.3% while GAS TSS mortality is >30%.
In this case the failure of the FY2, Dr Evans, to fully examine Calum’s wound, which would have probably prompted the consideration of a wound infection, is significant and may well have contributed to Calum’s death.
This was compounded by Dr Evans’s failure to communicate all the relevant details of the child’s case to the registrar, Dr Riley, with whom he discussed the case. Even though Dr Evans may not have been aware of the possibility of TSS, the mention to Dr Riley of a recent burn may have prompted the re-evaluation of Calum prior to discharge.
Legal comment
The family have not yet made a complaint. But if they instruct an expert to look at the case, he may well criticize the failure of Dr Evans to examine the scald wound and his failure to mention it to the registrar, Dr Riley, when Calum first returned to the hospital. But in terms of a claim in negligence, the real question is whether an examination at that time would have altered the outcome. If the correct diagnosis had been made and appropriate treatment had been administered, would Calum’s life have been saved? As ever, the expert will have to provide an answer on the balance of probabilities. It appears that prompt action may well have made a difference. If so, the family will receive compensation.
