Hot Seat Case # 119: 2 yo fever and rash
Posted on: October 18, 2018, by : Sarah Isbey
Sarah Isbey, MD Children’s National Medical Center
with Alyssa Abo, MD Children’s National Medical Center
A two year old male presented to the ED for evaluation of fever and rash. Mother reported that he had been febrile for the past 5 days, Tmax 102.5, improving with antipyretics but returns as soon as they wear off. Mother noted rash to his body, as well as swelling to his hands and feet. He is very irritable, eating and drinking less than normal, and making less wet diapers than normal. She denies sick contacts, though he is in daycare.
Constitutional symptoms: Fever, decreased appetite, decreased urine output.
Skin: Rash and swelling of hands and feet.
Eyes: No redness or discharge.
ENMT: Nasal congestion, no oral lesions mother has seen
Respiratory: No coughing or difficulty breathing.
Gastrointestinal: No vomiting, no diarrhea, no blood in stool.
Genitourinary: No hematuria.
Neurologic: Irritable but alert and active with medications
Hematologic: No petechiae or bruising.
PMHx: No hospitalizations, no surgeries, no chronic medical problems
FHx: Uncle with history of Kawasaki’s disease
Social: lives with mother and grandmother
PE:
VS: T 39.0, HR 188, RR 28, BP 132/90 (screaming), O2 Sat 100% on Room Air
Skin: Warm, dry, pink. Diffuse slightly raised erythematous rash on arms, legs, and trunk. Swelling to hands and feet with mild peeling near nailbeds
Head: Normocephalic, atraumatic.
EENT: Mild diffuse conjunctival injection. Moist mucus membranes, no mucus in nares. Lips without erythema or peeling. Tongue appears normal.
Cardiovascular: Tachycardic regular rhythm. No murmur or gallop. Femoral pulses present and equal bilaterally. Capillary refill of 3 seconds.
Respiratory: Clear to auscultation bilaterally
Gastrointestinal: Abdomen soft, non-tender, and non-distended. No palpable masses or organomegaly.
Back: No appreciable tenderness. Normal alignment, no step-offs.
Musculoskeletal: No deformities noted and able to move all four extremities
Neurological: Irritable, purposefully tries to get away from examiner, moves all 4 extremities.
Lymph: small (<1 cm) cervical chain lymphadenopathy bilaterally. No supraclavicular or inguinal nodes
Labs significant for:
WBC 22.7 with 39%N and 5% bands, H and H 10.1/29.5, Plts 438
ESR 57 CRP 9.49
CMP notable for Na 133.
Urine bag placed , but the patient has not urinated.
You attempt to give a NSB and the IV infiltrates. He is still febrile with HR 207 (while resting in mother’s arms). Repeat BP 94/40. Over the next 30 minutes, multiple nurses attempt for a total of 9 times without success. The patient is refusing all PO and is awake and alert, but BP continues to trend down to 85/40 and capillary refill is up to 4 seconds.
You call the PICU for an US guided IV but they are unable to find a site. Anesthesia is in the OR but can come down as soon as they are done (approximately 45-60 min).
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This sounds like a case of “Kawa-shocky” syndrome (Kawasaki with cardiogenic shock). He’s got 5 days of fever plus rash, hand/feet swelling/peeling, conjunctival injection, and some lymphadenopathy. I think this kid also needs an urgent Echo to assess myocardial function. If concerning, admission to CICU may be considered.
Agree with Dewesh, definitely screams KD. Also agree the echo should happen ASAP in the ED for this kid to help decipher if this is truly cardiogenic vs. distributive shock and therefore disposition. In terms of access, sounds like this is a child that truly needs it the sooner the better. IOs obviously hurt in the awake patient, not sure if lidocaine will truly make it that much more pleasant. If the echo is normal and hes not tanking in front of your eyes, I would probably opt for the NGT now while we wait for further access and start hydration that way.
I would agree with the above comments, the history, physical and lab findings are consistent with KD and I agree that the patient needs a bedside echo. The SBP remains okay for her age but the DBP is definitely trending down and the HR is high but the child is also extremely irritable. It might be helpful to obtain a blood gas to assess the lactate to get a sense of tissue perfusion…though I recognize that you might not be able to get labs. Having put in an IO in an awake patient with lidocaine I would argue to go that route. You need to prime the tubing and then you slowly infuse the lidocaine over 120 seconds and allow it to dwell in the IO space for a full minute. This is not a crash setting so you can do this in a controlled manner and take your time. While drilling into the bone sounds horrible, it is actually well tolerated if you allow the lidocaine adequate time to work. This will be a bridge to definitely access. I would also be wary of using an NG if you are concerned about shock and gut hypoperfusion in this patient.
Agree with KD.
Wondering for the reason why some providers would place an NG before an IO in this case? To be perfectly honest I’ve never placed an IO for dehydration and it has been shown to be as effective as an iv in patients with moderate uncomplicated dehydration:
Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration.
Nager AL, Wang VJ.
Pediatrics. 2002 Apr;109(4):566-72.
I feel this patient is more complicated and in shock and an NG would just not deliver fluids as effectively/quickly as an IO. As Christina stated the gut would most likely be hypoperfused at this point. I’ve used with lidocaine also at it’s surprisingly well tolerated. Also if this patients worsens further intubation may be necessary and I wouldn’t want to do that with a belly full of fluid if it can be helped.
Agree with the above comments… this case does seem consistent with KD. While all the criteria are not there, “irritability” is definitely a clue (anecdotal experience). For access, I would like to see US introduced sooner into the options above. Most of the PEM fellows and ED techs are familiar and I think it would be a reasonable place to start. Also, what about an EJ before an IO or central line? I agree NG is a bad idea… I also wouldn’t want to stress the kid out even more when his HR is already 207.