Hot Seat #185: DenouementPosted on: February 24, 2022, by : Walter Palmer
This week we highlight the case of a child with altered mental status and unusual mixed metabolic derangements. The initial management was complicated by an incomplete clinical history and delay in obtaining Creole interpreter services.
Most respondents agreed that, given the initial clinical impression of an uncomplicated child with mild dehydration, there was no further workup or management recommended prior to transport. Once the child arrived, junior and senior respondents generally agreed that obtaining a point of care VBG was the first step. Once initial labs returned with acidosis and hyperglycemia, there was less consensus. Most agreed that continuing IV fluid bolus was indicated given the clinical history of GI distress and delayed capillary refill, suggesting dehydration. Some however voiced concern that excessive IV fluid may exacerbate potential intracranial hypertension.
The acidosis and hyperglycemia raised concern for DKA. Junior respondents were more likely to choose to initiate empiric hypertonic saline, whereas senior respondents were more likely to start with head CT for evaluation.
Ultimately, the NS bolus was finished and HTS was given empirically. CT head showed abnormal white matter hypodensities most prominent in the bilateral parietal lobes and parts of the frontal lobes, as well as partial effacement of sulci in the bilateral parietal lobes, consistent with chronic gliosis. Radiology called to inform the provider that these findings are atypical for cerebral edema seen in DKA and are likely not acute. The virtual interpreter was acquired and the patient’s parents revealed that he has muscular dystrophy. He is normally verbal and interactive, but this posturing is typical for him. Endocrine was paged and recommended against starting insulin. After a third NSB, he became much more alert & interactive. Repeat labs showed persistent but improving hyperglycemia to 450. His HbA1c was normal so DKA treatment was never started. In the end, he was diagnosed with dehydration in the setting of viral enteritis with iatrogenic hyperglycemia caused by the D50 administration. After a brief admission to the ICU, the patient was discharged home in his usual state of health.