Hot Seat #238: 6 year old with nausea and vomiting
Posted on: October 29, 2024, by : Haroon Shaukat MD
Alicia Rolin MD, Children’s National Health System
with Haroon Shaukat MD, Children’s National Health System
Patient is a 6-year-old male with autism spectrum disorder who presents with nausea and vomiting. Parents report that for the past 2-3 days he has been feeling unwell. Report tactile fevers and rigors. Has had multiple episodes of NBNB emesis. Decreased PO intake. Developed frequent diarrhea in the past 24 hours. No blood in the stool. Uncertain about urine output. Appears more tired and less interactive than usual. At home, he had an episode of appearing pale and had fecal incontinence, so they presented to the ED for further evaluation. Brother and parents with URI symptoms at home. No recent travel. Went to a sporting event 5 days ago. Of note, parent report his older brother has a folate deficiency that causes similar appearing episodes of lethargy.
PMH: Autism spectrum disorder (has only 2-3 words)
PSHx: Bilateral tympanostomy tubes
Meds: No daily medications
Allergies: No allergies to foods or medications
Immunizations: Up to date with the exception of COVID and influenza
Vitals: T38.5C, HR 122, RR 14, BP 85/50, SpO2 95% on RA
General: Tired appearing school age child in no acute distress
HEENT: atraumatic, sclerae clear, nose and ears externally normal, dry lips, no oral lesions
Neck: no lymphadenopathy adenopathy
Resp: CTABL, non-labored breathing
CV: Tachycardia with regular rhythm. No murmurs, rubs, or gallops. Cold and clammy extremities. Capillary refill 3-4 seconds.
Abd: Soft, non-distended. Does not grimace or push you away with palpation. No organomegaly. Normal external GU exam.
MSK: baseline range of motion
Skin: no rashes
Neuro: Tired but arouses to touch. PERRL. Withdraws to pain. Normal muscle strength and tone. Minimally verbal at baseline. Parent reports that he is less interactive than his baseline.
Labs notable for pH 7.1, Na 123, glucose 30, lactate 7. COVID positive. Able to draw labs but were unable to place an IV. Vitals remain HR 122 with BP 85/50.
A medical alert was not called. An IO was placed and the patient was given a D10W bolus.
Starting on aggressive IV fluid resuscitation with 60 ml/kg of D5NS bolus.
After fluids, called to bedside. He is now hard to arouse, mottled, grey and hypotensive (BP 63/42 MAP 50). They only have an IO for access. SpO2 in the 80s. Placed on 4L NC.
After improving hemodynamics, decision is made to intubate due to altered mental status.
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Initially, my ddx for this patient in most likely hypovolemic shock included acute gastroenteritis complicated by hypoglycemia, sepsis, HUS, acute streptococcal infection, or an ingestion (wide tox differential including iron, substances causing methemoglobinemia, alcohol, etc.). I agree with initial management, though I would have added some tox labs including an iron level. I would also get a travel/camping/hiking/animal exposure history to r/o any weird AGE situations.
After he was found to be hypotensive/poorly perfused and altered following fluids, I would want to know if his liver was now down (myocarditis et al.) to guide further fluid resuscitation and pressor selection if necessary. In addition, it’s now med alert time, paying attention to airway (position, eventually control), breathing (100% NRB, intubate), and circulation (fluid management and pressors depending on whether we think it’s now cardiogenic, hypovolemic, or septic shock or a combination of the three). I would check his glucose a second time and check and see what his hemoglobin is on an istat (does his acute illness or a med he has taken predispose him to a crisis of an RBC illness like spherocytosis/elliptocytosis/G6PD/PK deficiency)? In addition, I would take this opportunity to get a methemoglobin level using our co-oximeter.