Paediatric Protocol

Renal: 6.2

January 2001

TOXIC SHOCK SYNDROME

Definition: This is a syndrome characterised by the sudden onset of high fever, vomiting, diarrhoea, skin rash and, ultimately, by acute shock and hypotension. The most common cause is usually Staphylococcal. Aureus ,followed by Streptococcus and is exotoxin mediated.

Association: burns (may often be small percentage burns), wounds, tampons, tracheitis, pneumonia and empyema

Age: may vary from neonates, to young children with burns,to older.teenagers.

Burns patients:

Time of onset: 1-3 days post-burn

Mortality: overall 10%; in cases of full blown shock, 50%.

Characteristic features
  • Fever > 38.9oC
  • Rash: diffuse macular erythema
  • Hypotension and poor peripheral perfusion
  • Vomiting or diarrhoea
  • Severe myalgia
  • Mucous membranes inflamed and red
  • Renal impairment
  • Hepatic impairment
  • Thrombocytopenia
  • C.N.S. alterations in consciousness

Note: Diagnosis is initially on a clinical basis. Do not delay treatment in suspect cases while awaiting laboratory report. These may confirm diagnosis later but should not delay treatment.

Laboratory diagnosis

Send standard swabs requesting relevant phage type and production

of TSST-1 toxin

  • 125 microlitres of serum(plain clotted bottle) to demonstrate absence of Staph. antibodies)
  • P.C.R. for detection of genes for Staph Aureus Enterotoxins, 100 microlitres of serum (plain clotted bottle)
  • (The above two samples should be sent to microbiology who will then forward them to the Public Health laboratory,London)
  • Blood C & S.
Investigations

Bloods:

f..b.c., u & e, coagulation, l.f.t.’s, c.p.k., pH
  • serum myoglobin,
  • blood c&s

Urine:

  • c&s, u & e and osmolality

Stool:

  • C & s

Swabs:

  • wounds, nose & throat

Mortality secondary to:

  • irreversible shock
  • respiratory failure
  • cardiac dysrhythmia
  • coagulopathy
  • cerebral ischemia
Management (1)
Guidance in high dependancy unit

On arrival, discuss with:

  • Burns Consultant
  • Consultant in Paediatric Nephrology
  • P.I.C.U. Consultant

Immediate treatment

  • Initially, 4.5% H.A.S. 10 mls/kg and arrange
  • Fresh frozen plasma 10-20 mls/kg (may need C.V.P. line)
  • I.V. antibiotics Flucloxacillin 50mg/kg q.d.s., Gentamicin (see Medicines for Children, p245-246).Later modifications to this may be needed dependent on microbiological results and discussion with Consultant Microbiologist
  • I.v. immunoglobulin (see manufacturers directions for infusion, rate and dose)

Consideration must be given to identifying the source of infection and if feasible it’s rapid removal.

Full supportive treatment

  • Reduce maintenance to 70% of normal requirements whether i.v. or oral, aim for plasma osmolality 280-320 mosm/kg
  • Electrolyte homeostasis: most children are hyponatremic this may be due to water overload, inappropriate A.D.H. or sodium depletion due to excess losses. Commence with 0.45% saline/dextrose
  • Consider fresh blood if no F.F.P. available or if very anaemic transfuse

Management (2) – Monitoring

Temperature:

  • core & peripheral temperatures
  • control temperature with antipyretics
  • Temp. gap of > 3C ? => due to hypovolaemia
  • if yes, correct with I.V. 4.5% HAS 10-20 mls/kg

Fluid balance:

  • Urinary output – aim for minimum of 1 ml/kg/hour
  • Monitor urinary biochemistry (paired osmolalities)

Blood:

  • Biochemistry (including b.m.’s)
  • Gentamicin blood levels

Cardiac:

  • Blood pressure/heart rate (half hourly)

C.N.S.

  • Use Glasgow Coma Scale
  • Do not assume restlessness due to full bladder or other problem without evidence
  • N.B. Lumbar puncture is absolutely contraindicated due to risk of coning with possible cerebral oedema

Note: For ventilation and management of fits refer to individual policies

References
  1. Handbook of Pediatric Intensive Care, Ed. M. C. Rogers & M. A. Helfaer, 3rd Edition.
  2. “Multiplex P.C.R. for detection of genes for Staph. Aureus Enterotoxins, Exfoliative Toxins, T.S.S.T.1 and Methicillin resistance”, Journal of Clinical Microbiology Mar 2000, pp. 1032-1035
  3. “Toxic shock syndrome after burn injuries in children” Scand J Reconstr Hand Surg 1997, 31, pp. 77-81.

MEDICAL GUIDELINES POLICY

ISSUE:2VERSION:FINAL

Title:Toxic Shock Syndrome

Author:Frances Neenan

Job Title:Paediatric Specialist Registrar

First Issued:July 1997Date Revised: January 2001

Review Date: January 2003

Document Derivation:Consultation Process:

References:PICU Consultants

Included in protocolBurns unit

Paediatric Nephrologists

Ratified by:Paediatrics Protocols Committee

Chaired by:Dr Ryan Watkins

Consultant with Responsibility:Dr Stephanie Smith

Distribution:

All Wards QMC & CHN

A.MANUAL AMENDMENTS RECORD

(please complete when making any handwritten changes/amendments to protocol and not processed through protocol committee)
Date / Author / Description

Page 1 of 5