Alicia Rollin MD, Children’s National Medical Center

Case: This is a 6-year-old patient who presented initially with several days of fever, vomiting and diarrhea. Found to be profoundly hyponatremic and hypoglycemic in the setting of diarrhea and poor PO intake. On arrival, he was febrile, tachycardic, and hypotensive. Labs notable for pH 7.1, Na 123, glucose 30, lactate 7. COVID positive. IV access was difficult but ultimately an IO was placed for fluid resuscitation.

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Discussion:

Everyone noted this child had abnormal vital signs in triage, however, this can sometimes be difficult to assess if these abnormalities are secondary to fever alone or will persist. It is always important to remember to follow abnormal vital signs until they resolve if we think this is due to fever, otherwise, treat and jump on them. The resuscitative fluid of choice for many was either LR or NS, however, Dr. Agrawal reminded us that bolusing with dextrose containing fluids (D5-NS) in presumed gastroenteritis can be beneficial. A study found that this bolus did improve the metabolic profile and help clear ketones faster (allowing the child to symptomatically feel better) however it did not change admission rates for pediatric patients.

We also discussed a broad differential for this patient including not forgetting intrabdominal pathologies such as perforated appendicitis leading to septic shock.

Finally, we discussed the nuanced presentation of myocarditis and that it is often a diganostic dilemma unless the patient is in obvious extremis. Remember, that a patient who has worsening tachycardia after fluid resuscitation or acutely worsens after fluid administration should always have myocarditis on the DDX. Click here to learn more.

Denouement:

He was ultimately diagnosed with myocarditis.

The patient received a total of 80 ml/kg of IV fluids and started on epinephrine and norepinephrine continuous infusions @ 0.3 micrgrams/kg. He was empirically started on ceftriaxone and vancomycin for concerns of septic shock. OSH had completed LP which was bloody and difficulty to interpret. Given AMS, he was intubated. POCUS demonstrated poor cardiac function without effusion.

In the PICU, approximately 1 hour following intubation, called to patient room for desaturations. On exam, mottled, poor perfusion, liver edge ~3cm below coastal margin. QRS morphology changed and the ETCO2 < 15. He was pulseless and CPR was started. He alternated between PEA and VT. Initial arrest ~20 minutes during which he received multiple doses of epi, calcium, bicarb, adenosine, and amiodarone.

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