Hot Seat #88: 17yo F in cardiopulmonary arrest
Posted on: February 13, 2017, by : Rachael Batabyal MD
Rachael Batabyal MD, Children’s National Medical Center
with Theresa Walls MD, Children’s National Medical Center
The Case
A 17 year old female with no past medical history is brought in by ambulance s/p cardiopulmonary arrest at home. 3-4 days prior to arrival, she had developed emesis and diarrhea. She was treated at home with over the counter activated charcoal. She has been afebrile but had been getting progressively more tired and eventually difficult to arouse over the past few days. Parents called EMS when patient became unresponsive at home on the morning of presentation. When EMS arrived, the patient was found to be in asystole. EMS initiated CPR in the field and intubated the patient. After 15 minutes of chest compressions and 4 doses of epinephrine, she had return of spontaneous circulation. She remained hypotensive with a systolic blood pressure in the 50’s, and a dopamine infusion was started in the field.
ROS: unavailable
PMH: unavailable
PE:
VS: BP 50/30’s, HR 160 on monitor, 80 by palpation, SpO2 66% on peripheral pulse ox, 100% when moved to earlobe
Gen: unconscious, intubated, ill appearing
HEENT: NCAT, pupils equal, 2-3, sluggishly reactive, intubated with 6.5 cuffed ETT
Neck: trachea midline, no JVD
CV: RRR, no m/r/g appreciated, cap refill is 3 seconds, +weak distal pulses present
Resp: Lungs CTA b/l, no wheezes/rhonchi/rales, chest wall without deformities
Abd: soft, distended, no hepatomegaly, no bruising
Ext: cool, no swelling or deformities
Skin: warm, dry
Labs/Radiology:
VBG: 6.85/78/79/13.7/Base deficit: 22
POC Na: 133 POC K 6.0, POC Glucose >700, Lactate 8.88
CXR: unremarkable
EKG: HR 82. Notable for widened QRS and peaked T waves.
Bedside echo: normal function
The patient was started on an epinephrine drip, a norepinephrine drip, and an insulin drip. She received vancomycin and ceftriaxone. Blood pressures stabilized with SBP in the 90’s.
Questions:
It is later discovered that patient had been incontinent of urine for several days, and no medical care was sought during that time. The family explains that they have strong religious beliefs, and in the past they have healed their children through prayer.
One last question:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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Wow what a case…
Frozone(from the Incredibles): “Altered mental status, profound acidemia, adult diapers, presumed DKA….honey, WHERE is my SUPER SUIT? aka the rest of the basic metabolic panel? ASA and APAP levels? Toxic alcohol screen? head CT?
Healing children by prayer alone. About as appealing as vegan parents giving their newborns soy milk. Terrible! (oops did I just say that… )
Wow, indeed! In the throes of cardiopulmonary arrest, we can’t think about why this happened, only how to fix it. Once there is ROSC, we can focus on her profound acidosis, hyperglycemia, & hypotension. As Dr. Kou mentions, we’ll need more information. I’d love to know the full bmp (chloride, BUN, repeat K) and see what a UA shows.
The acidosis & EKG changes make me think of tox, but when I get the history that this has probably been brewing for a few days, I think that severe DKA is more likely. One way to tie this together nicely would be DKA –> super acidotic –> hyperkalemia –> wide QRS & peaked T waves –> asystole. But the K is only 6.0, and these kind of symptoms are usually when the K is 7-8. Hmmmm. Or is it horrible cerebral edema? This is typically supposed to happen within 12 hours of the initiation of therapy for DKA, but can (rarely) happen prior to treatment. This is where more info, even a quick call to poison control to talk over her symptoms, can be helpful. (call made by someone other than me who’s not at the bedside resuscitating this patient, that is!)
If DKA is what we’re dealing with, then she needs insulin and fluids. I voted to give her sodium bicarb, mostly because of the profound acidosis and wide QRS on her EKG. A (very!) quick lit search reveals that bicarb MAY be indicated in patients with severe acidosis (pH<6.9) and cardiac dysfunction (like asystole!) from DKA but it has lots of risks.
I voted for no mannitol or bicarb right now. It certainly is reasonable to consider cerebral edema, and I might end up giving either of them soon, but at this point I think her mental status seems consistent with severe acidosis/arrest. She is relatively bradycardic for how dehydrated she must be, but her hypotension doesn't fit with severe edema/impending herniation.
I would definitely get social work involved in the ED if there's time. Whether or not there was neglect, this family is dealing with a traumatic event-their child almost died (and still may die soon). Once I heard about the incontinence & prayer, it made me much more likely to think about CPS. However, this child is going to the PICU, not home from the ED, so I would just make sure that the PICU team was aware of my concerns. If social work is involved, they can be enormously helpful in making these calls and ensuring that nothing falls thru the cracks when the patient is transferred to a different area of the hospital.
See you all on Thursday!