When a Child Comes to the Emergency Department Altered...

Donna Moro-Sutherland, MD; Ghazala Sharieff, MD

Disclosures

July 30, 2010

Case Presentation

Chief complaint: Decreased activity, "not acting himself"

History of present illness: A 21-month-old boy was traveling from West Virginia to visit his grandparents with his family when he had a change in mental status early in the morning, at around 8:30 a.m. He seemed to be somewhat lethargic and unresponsive. Because of the clear changes in sensorium, his parents rushed him to the hospital. They stated that he was pale and clammy, and was waxing and waning in mental status on his way to the emergency department (ED). They had arrived in town 2 days ago and noted that the child had some nasal congestion, which they attributed to the grandparents' dogs in the home. Because of the persistent congestion, they gave the patient 1 teaspoon of Benadryl® the night before and three quarters of a teaspoon of Dimetapp® at about 5 a.m. on the morning of presentation. His parents reported no trauma, ingestion, or fever. The patient had a slight decrease in appetite but good urine output. He had no vomiting or diarrhea and no history of seizure activity at home.

Past medical history: The patient was born at 35 weeks gestation via cesarean delivery because of failure to progress. He had no other hospitalizations. He has up-to-date immunizations and no known drug allergies.

Physical Examination

Vital signs: temperature, 95.6°F (rectal); heart rate, 116 beats per minute; respiratory rate, 24 breaths per minute; blood pressure, 83/47 mm Hg; room air oxygen saturation, 100%; weight, 11.2 kg
General: carried to the room by nursing staff and placed on a stretcher; appears to look around but not focused; withdraws from pain; does not answer questions
Head, eyes, ears, nose, and throat: normocephalic, atraumatic; pupils equal, round, reactive to light and accommodation; extraocular movements intact; no hemotympanum; no rhinorrhea; moist mucous membranes
Neck: supple; negative for Kernig and Brudzinski signs
Lungs: clear; no rales or wheezes
Cardiovascular: regular rate and rhythm; no murmurs
Abdomen: soft, nontender, no organomegaly or masses
Genitourinary: circumcised male; testes descended
Neurologic: localizes pain; no clonus; reflexes 2+ in upper and lower extremities; no Babinski reflex
Skin: warm, dry, no rashes

ED Course

The child was undressed and placed on a monitor. An intravenous line was placed and an i-STAT® panel was obtained because of the concern of altered mentation.

Results revealed the following: pH, 7.2; PCO2, 41.5 mm Hg; PO2, 30.0 mm Hg; HCO3, 16.3 mEq/L; TCO2, 18 mEq/L; sodium, 135 mEq/L; potassium, 3.7 mEq/L; glucose, 47 mg/dL; base excess, -12; hematocrit, 39%

Because the patient's glucose level was 47 mg/dL, nursing was instructed to draw a battery of tests and administer 40 mL of D25. The workup in the ED included a complete blood count, blood culture, urinalysis, urine culture, chemistries, liver function tests, ammonia, amino and organic acids, cortisol level, insulin, growth hormone, carnitine, and lactate. Toxicology screen included salicylates, acetaminophen and ethanol, and coverage with ceftriaxone secondary to the unexplained hypothermia. Computed tomography (CT) of the head was performed because of the change in mentation without a clear cause.

During the patient's first hour in the ED, he began conversing with his parents. Approximately 1 hour after administration of D25, a repeat glucose was 195 mg/dL. The child's neurologic examination continued to improve, and his temperature returned to normal. Because the child did not appear encephalopathic or meningitic, a spinal tap was decided to be considered only if his condition deteriorated. The child was admitted for observation. The next morning, he was running around and no longer receiving glucose, without any recurrent episodes of hypoglycemia.

Laboratory and Radiographic Studies

CBC: WBC, 28.1 cells/μL/cubic mm; differential, 85% segmented neutrophils, 10% lymphocytes, 4% monocytes
Urinalysis: specific gravity, 1.021; moderate ketones; negative glucose; negative reducing substrates
Metabolic panel: sodium, 133 mEq/L; potassium, 3.6 mEq/L; chloride, 101 mEq/L; CO2 mEq/L, 19; glucose, 51 mg/dL; AST, 44 IU/L; ALT, 25 IU/L; albumin, 4.5 g/dL; anion gap, 13 mEq/L
Lactate, 1.1 mg/dL
Venous ammonia: 46 µmol/L
Cortisol: 39.1 µg/dL
Toxicology screen: negative (acetaminophen < 10 µg/mL, alcohol < 10 mg/dL, salicylates < 4 mg/dL)
CT of head: negative

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