Chisom Agbim, MD, Children’s National Medical Center

Case: 11 mo female brought in by grandmother after a 30 minute episode of unresponsiveness at home. No known ingestions to trauma, however in a house with multiple medications and under the care of her grandmother while her parents were out of town. She had a normal exam, labs, and remained stable through a period of observation

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Discussion:

This case is in my mind what differentiates a PEM trained physician from an EM trained physician. The ability to truly rely on an infant physical exam as your only source of information to work with given not only a lack of history. But, also a lack of the caretaker witnessing the event be present. The general consensus of the room as well as commentators on the original case post felt that seizure, intoxication, and non-accidental trauma/neglect were at the top of the differential.

For those that suspected intoxication, the agreement were that given the history of what medications are in the household, an intoxication workup (urine and serum) would likely be unremarkable. However, one still needs to obtain them.

The real crux of this case was the disposition of this infant. Do you let them go? Keep them in the ED? or admit? There are arguments for each! The parents seemed very reliable to the treating physician (clearly not the caretakers but that’s another story!) so opening the CPS case for possible neglect and allowing the patient to be discharged with the parents does not seem unreasonable. Observing further in the ED would be nice because not only does it allow you to continue to monitor the child (for possible recurrence of a seizure) but, also allows you to get a feel for the parents ability to care for this child. Finally, admitting for 24 hours gets you not only prolonged medical attention to this infant, but, may also allow you to get a routine EEG complete to help with the workup.

Denouement:

Poison control was notified and recommended 24 hour inpatient observation due to concern for delayed reaction to sitagliptin and metformin HCl and risk for profound hypoglycemia. Although hydrochlorothiazide and losartan were also in the patient’s house, ingestion of these medications were determined to be unlikely considering the patient’s lack of hypotension, tachycardia and bradycardia several hours following the patient’s period of altered mental status. The patient had stable vitals and blood glucose levels throughout admission. She was discharged in the care of her mother.

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