As you flip through the charts the first is a 'sprained ankle' and the second is 'a bad cold'. You note that the age on the 'cold' patient is only three weeks. You decide to walk out to the waiting room to eyeball the baby.

Mom has her baby bundled up, and after introducing yourself, you ask if you can do a quick check while waiting for the triage nurse. Mom notes, "He won’t take his bottle, and I think he has a cold, my other son is sick with a cold".

As you peel back the blanket, you become alarmed when you note the infant has mottled coloring, is grunting with a very fast RR (with retractions) and after checking for equal breath sounds, you note that the heart rate is over 200.

The infant is quickly brought into the critical care area, and you request the usual six things (IV (normal saline, bolus with 20 cc/kg), oxygen, monitor, undress the baby, get me complete vital signs, and draw some blood).

As you start your primary survey, mom provides some initial information when questioned.

Mom noted she brought the baby to the ED because she thought he had a ‘cold’ and that the baby had been sick for the past 24 hours. He had an occasional cough and would start to cry when he tried to feed. Now he didn’t want to even try to take the bottle and baby's brother has a cold.

PMH: baby was full term, 7 lbs at birth (per Braslow tape is now 3.4 kg), had a normal two week doctor visit, and vaccinations were up to date. There was no complication with the birth, and baby went home with mom (Vaginal delivery).

Your quick survey reveals the baby to have a flat fontanel, dry mm, supple neck. Air way open, no cry to IV attempts, baby is grunting.

Heart Tachycardic with HR 230. (monitor showing narrow complex Tachycardia) No murmurs.
Lungs: retractions are noted, no rales or wheezing, equal breath sounds.
Abd: soft, no masses, nl umbilicus.
Ext: peripheral cyanosis, no palpable pulses except the brachial area.
Neurologic: floppy, minimal movement
Nurse reports VS: HR 230, RR=80, unable to pick up blood pressure with cuff, unable to get oxygen saturation.

You order cbc with diff, lytes, BUN, Cr, glucose and U/A and urine and blood culture. CXR and EKG were also ordered.

The nurse is unable to get an IV. She has looked at both hands, and antecubital areas.

1. Where else can you look?

2. What lab test (in addition to those listed above), needs to be done stat!

3. What additional information do you need from the nurse?

4. What else needs to be done?

5. How often is the blood culture positive when a child has meningitis?

6. What factors increase risk of death in neonates with sepsis?

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