Infectious toxicosis

Infectious toxicosis is an emergency that can occur with any acute bacterial or viral infection in children from 3 months to 2 years. Patients with infectious toxicosis account for 7-9% of all patients entering the intensive care unit with infectious pathology.

According to some data, in 53% of cases in infants with infectious toxicosis, the invasive form of OCD was proven, and in 27% - viral-bacterial associations of pathogenic bacteria with respiratory viruses.

The main link in the pathogenesis of infectious toxicosis is the sympathoadrenal crisis.

[1], [2], [3], [4], [5], [6]

Symptoms of infectious toxicosis

In most children, the disease begins violently and unexpectedly with a rise in body temperature to 39-40 ° C, vomiting, restlessness, and liquid stool 3-4 times a day. Only in 11% of cases, parents note that on the eve of hospitalization the child was capricious, poorly ate, trembling in a dream. In 53.4% of cases, children develop clinical-tonic convulsions or convulsive twitchings, and in 26.6% they start at home.

In all patients with an unclosed large fontanel on admission, one of the three conditions is noted, the fontanel is made, bulging or pulsating. This is a characteristic feature that makes it possible to distinguish infectious toxicosis from intestinal exsicosis, in which a large fontanel always sinks.

All children are characterized by hyperthermia from 38.8 to 40.5 ° C, tachycardia 180-230 per minute, hypertension, respiratory distress 60-100 per minute, which indicate an increased sympathoadrenal activity. The color of the skin is varied from hyperemia to severe pallor with cyanosis of the nail plates. Mark pastovnost eyelids and tibia CVP normal or elevated. A constant sign of infectious toxicosis is a decrease in diuresis, although it is noted in other urgent conditions.

All patients develop neurological disorders. In 58.6% of cases, negativism and acute anxiety, monotonous crying and hyperkinesis are noted. The rest of the patients come in hand. All children notice an increase in tendon reflexes, an increased tone of the limbs. In 43.1%, stiff neck muscles are found, in 38% - convergent strabismus with narrowed pupils. In patients, there is an increase in systolic and diastolic blood pressure by 20-40 mm. Gt; Art. The clinical picture of infectious toxicosis differs a great variety due to disorders in many organs and systems. Only those of the symptoms that develop in almost all patients are listed.

Signs of infectious toxicosis in children

Symptoms	Characteristic values
Neurological disorders
Consciousness	Anxiety, sopor, coma
Muscle tone	Hyperkinesis, muscle tone increased, rigidity of the occipital muscles
Physical activity
Convulsions	Often - convulsive twitchings, clonic-tonic convulsions, not cramping convulsions
Tendon reflexes	Hyperreflection
Circulation
HELL	Increased 100 / 70-140 / 90 mmHg
CVP	Normal or increased
Heart Rate	Tachycardia or paroxysmal tachycardia 180-230 per min
Large fontanel	Completed, bulging, throbbing
Temperature	Hyperthermia 38 8-40,5 С
Signs of excision	Not expressed
Urinary system	Rare urination, azotemia, proteinuria
Dyspnea	Tachypnea - 60-100 per minute
CBS
PH	Metabolic acidosis 7.22-7.31
BE	Deficiency of bases -8 -17
PC02	Hypocapnia 23,6-26,8 mm Hg
LII	2.9-14
Leukocytes	12.8-16x10 9 / L
DIC-Syndrome	I-II-III stages

From the tactical point of view, it is expedient to distinguish the following clinical variants of infectious toxicosis: the encephalic form, edema of the brain and paroxysmal tachycardia. The isolation of these forms is necessary for the selection of pathogenetic therapy. With untimely intensive therapy, paroxysmal tachycardia is complicated by cardiogenic shock.

The encephalic form occurs more often than others (82-83%), cerebral edema - up to 7%, and paroxysmal tachycardia is about 10%. In the latter case, the question is solved by ECG or monitor monitoring.

When paroxysmal tachycardia in children, the pulse rate exceeds 200 per minute, the tooth P due to frequent contractions is layered on the tooth. T The interval ST below the isoelectric line.

Edema of the brain in patients is characterized by a coma, a convergent strabismus, non-stopping convulsions, which serves as the main differential sign. With spinal puncture, high blood pressure is noted; in CSF, in clinical analysis, there are no signs characteristic of meningitis or encephalitis.

Thus, for infectious toxicosis there are no strictly specific signs. But the combination of laboratory-functional data and described clinical symptoms with a predominance of neurological disorders and signs of increased activity of the sympathoadrenal system allows one to diagnose this emergency without special difficulties.

Treatment of infectious toxicosis

Intensive pathogenetic therapy of infectious toxicosis includes:

• cramping seizures and restoring adequate breathing,
• blockade of sympathoadrenal activity, restoration of adequate central hemodynamics and heart rhythm,
• prophylaxis and treatment of possible complications (cerebral edema, OSN and violations of the excretory function of the kidneys).

Cramping convulsions is carried out with the help of general inhalation or intravenous anesthesia

Simultaneously, to stabilize the cell membranes, prednisolone is administered at a dose of 3-5 mg / kg or dexamethasone (dexazone) in an equivalent dose.

With repeated convulsions, a diagnostic spinal puncture is indicated. The absence in CSF of pathological cytosis (up to 16-20х10 ⁶ / l) and protein (up to 0.033 g / l) excludes neuroinfection in children and confirms infectious toxicosis.

The main method of treatment of hemodynamic disorders with uncomplicated forms of infectious toxicosis in young children is ganglion block.

Apply pentamine from the calculation of 5 mg / kg or any other drug of a similar effect, which is administered intravenously (20 drops per minute) in 50 ml of 5% glucose solution.

A paroxysmal tachycardia attack can be stopped with a nonselective beta-blocker or slow calcium channel blockers. Propranolol is administered by titration of 0.1 mg / kg per 10 ml of glucose, verapamil 0.25 mg / kg. The drugs block the effect of catecholamines on adrenergic receptors. Clinically, this is manifested by a reduction in dyspnea and tachycardia, a decrease in body temperature, a normalization of blood pressure, an increase in diuresis and an improvement in the color of the skin.

Infusion therapy at this stage is carried out with solutions that do not contain sodium salts, the average volume of infusion is 80-90 ml / kg. The total volume of fluid for the patient in the first day does not exceed 170-180 ml / kg.

In children with cerebral edema, in addition to the above measures, ventilation is carried out through a nasotracheal tube with the maintenance of pCO ₂ at a level of 33-34 mm. Gt; Art. The average duration of ventilation is 32 hours. It is important to transfer the child to the ventilator in a timely manner and to quickly stop the edema of the brain. In this case, the vast majority of patients can expect a full recovery of brain functions.

Indications for stopping ventilation are adequate independent breathing through the endotracheal tube, the absence of seizures, the restoration of consciousness and reflexes.

In the rehabilitation period, children who have undergone edema of the brain receive therapy and physiotherapy procedures under the supervision of a neurologist.

Timely and adequate intensive therapy of other forms of infectious toxicosis is effective, and the recovery period, as a rule, does not exceed 3-4 days.