Real EM case from residency

[lkth487]

I always think it's fun to do this (inspired by another thread).  This was a real case I had as an intern:

 

2 month old female comes to the ED, brought by dad for not acting like herself.  2 wet diapers today, nothing since this morning.  She is formula fed since birth and hasn't taken a bottle in the last few hours.   The feeding has gradually decreased for the past few days.  Dad checked for a temp at home, was 36.5C.  No one is sick at home.  No runny nose, cold, diarrhea, etc noted in the infant.  One episode of emesis earlier in the day (non bilious).

Weight is 3.5kg (dad doesn't know birth weight).  RR 60, HR: 160, T: 36.6C, BP: 65/30, SpO2: 94% in RA.  Exam shows tired infant with sunken fontanelle.  Will cry if you mess with her, but otherwise is quiet.  Consolable.  No murmurs.  Lungs CTAB.  Abd soft non tender.  Cap refill 3-4s.

What else do you want to know? Dx? Next steps?

[EMEDPA]

You didn't mention it, so I assume stripped for exam and no indications of trauma/abuse/petechiae, etc 

IV access, fingerstick glucose,  cbc, bmp, blood cultures, ua, 20 cc/kg fluid bolus, cxr, VBG,  reassess. tox screen if any suspicion for abuse or accidental od.  consider narcan if any suspicion for opiate exposure or pinpoint pupils. consider u/s if any concern for pyloric stenosis. consider LP if any suspicion for meningitis. consider carboxyhemoglobin if wood stove, concern for poor heating system in home, others with headaches, etc

[lkth487]

• Full stripped exam showed no petechiae or other indications of abuse
• No pinpoint pupils
• No one else in family with headaches or other sx
• I don't remember asking about wood stoves or other things - that's a good thought though
• Initial blood glucose: 64
• We got IV Access and started a bolus
• We got a CBC: WBC 14, Hemoglobin: 11, HCT: 34, Platelets: 160
• We did not get a LP
• Blood cultures sent
• There were no respiratory/cardiac sx other than some tachypnea, and did not obtain a CXR
• Did not obtain a VBG initially
• BMP: 
  • Na: 129
  • K: 2.5
  • Cl-: 108
  • CO2: 11
  • BUN: 8
  • Cr: 0.4
• UA
  • Glucose: negative
  • Protein: 1+
  • Ketones: 2+
  • Specific Gravity: 1.010
  • pH: 6.5
  • Nitriles: negative
  • Leukocytes: negative
  • Color: yellow

[EMEDPA]

K of 2.5 is interesting. cardiac monitor or ekg changes? replete potassium. co2 of 11 suggests significant acidosis. would get vbg or abg. 2+ ketones demonstrates this is a stressed kiddo. 

response to bolus #1? 64 is a bit low for the glucose, could give a bit to shoot for > 80 or attempt to feed some formula or dextrose solution. 

anything to suggest pyloric stenosis on exam? "olive mass in epigastric region" etc? 

[lkth487]

• No olive mass on exam, but I was thinking the same thing you are - and obtained an U/S for pyloric stenosis, which was normal
• No changes on cardiac monitor
  • We didn't replete K+ - it's a pediatric thing (even in PICU/NICU, we usually don't replete low potassium unless its SUPER low or we are symptomatic in some way).  I don't think its would have been wrong to replete.
• I wasn't too worried about the glucose, but we did feed the kid
• Perhaps a VBG might have been a good idea in retrospect, but we didn't get it at the time (VBGs/ABGs are rare outside of a patient you are intubating - or cases like DKA - in the pedi ED/ICU world - for better or worse).  
• Cap refil improved a little after a bolus, and she was more active.  Had two wet diapers (one before the bolus was even started, the other after the bolus)

[lkth487]

In the interest of full disclosure, at this point, I did not put it together.  I was going down the pyloric stenosis or sepsis tree.

But my pediatric emergency medicine attending had a strong suspicion for the diagnosis (which turned out to be right).

[EMEDPA]

no blood in diaper I assume(intususception). 

This is the point at which I would consult pediatrics. 

[lkth487]

10 minutes ago, EMEDPA said:

no blood in diaper I assume(intususception). 

This is the point at which I would consult pediatrics. 

No blood in diaper.  Unluckily for me, I was the pediatric intern (and didn't know).  But my PEM attending suspected the diagnosis and consulted Pedi Nephrology, which (after a few more tests), confirmed the diagnosis.

The patient had Type 1 (Distal) Renal Tubular Acidosis.  Clues were:  hypokalemia, and NON GAP metabolic acidosis (USEDCARP being the menmonic, with R being RTA), and urine ph > 5.5 presenting in a septic like or failure to thrive picture.  Learned my lesson to always calculate the anion gap!

The story didn't 100% fit RTA but that's the way it goes sometimes in real life...

[EMEDPA]

great case! Thanks!

[ventana]

Step 1.  Crap self (I know enough to know they are sick but not a clue)

step 2 change underwear (see #1)

step #3. Wake up from nightmare realuzung why I left EM.  

Step 4 thank the kind folks doing EM.  

[lkth487]

If a baby comes in looking septic, obviously it's sepsis until proven otherwise.  But a few things always go through  my mind:

• Failure to thrive
  • Congenital Heart Dz (look for feeding intolerance - such as cyanosis or getting tired with feeds, difference in BPs or pulse ox between right arm vs lower extremities, failure to thrive).  We've had more than one case of ALCAPA that was misdiagnosed as bronchiolitis at places that aren't used to treating many kids.  And definitely some missed structural congenital heart diseases as well.
  • RTA - generally kid comes in with polyuria but has a normal or low glucose (e.g not DKA) and losing weight.
• Genetic Disorders:
  • Specifically, things like inborn errors of metabolism:
    • Acidosis with high Ammonia levels in a baby, such as organic acidemias (or fatty acid oxidation defects if the kid is older)
    • Normal ph with high ammonia levels such as urea cycle defects
  • Urinary ketones, reducing substances are also helpful
  • Sometimes the clue is that some of these diseases appear a little later when the feedings are spaced out and you develop hypoglycemia
• Liver Failure
  • Biliary atresia - hyper conjugated bilirubinemia - you don't want to miss this one because Kasai procedure to fix this loses its effectiveness after the first few months of life, and then you have to have a liver transplant (I saw a few during residency that were missed).  Look for bruising, petechiae, jaundice, etc.
• Child abuse
  • Neglect or trauma
  • Always have to be on the look out for that
  • Things like retinal hemorrhages or subdural hematomas should always initiate a referral/workup for NAT
    • Don't forget there are rare cases such as Type 1 Glutaric Acidemia that can cause subdural hematomas and retinal hemorrhages - but that shouldn't stop you from automatic NAT evaluation
• Poisonings
  • Obvious

Appreciate people's thoughts about if I missed something major or if you would have done something else during your workup!

[lkth487]

I think EMEDPA was right - if I had to do it again, I would have gotten a VBG for the above mentioned reasons.  I also would have grabbed an ammonia and maybe obtained total and direct bilirubin (if at all jaundiced appearing).

[EMEDPA]

how often do you see hepatic encephalopathy in 2 month olds with high ammonia levels?????

[lkth487]

It's hard to know.  I've seen high ammonia come into the ED a handful of times in the three years of residency but I worked at a huge children's hospital, so I realize that's not the real world.  In the community, I think calling the nearest children's hospital and transferring after initial stabilization wouldn't be the wrong thing to do (esp. if they are close by).  And in general, I would say it wouldn't ever be the first line of test that I get unless the kid already came in with a diagnosis but if a kid is looking like they are septic but the sepsis story doesn't quite fit (lack of source, no temp. instability, going on for maybe a little longer than you'd expect), I might consider it as part of my second line of tests to figure out what's going on.  

[EMEDPA]

Thanks. noted for future practice. we have 2 excellent tertiary care peds referral hospitals 90 min away by ground or 20-30 min by air. 

[lkth487]

Yeah, I think it's more for just learning and thinking about rather than practical management.  I mean I'd expect our children's ED to do this workup because: A) all the docs there are pediatricians who then trained in PEM, so are familiar with the rare pedi stuff, and more importantly, B) they see >50,000 children per year, so there is zebras every day.  Experience is so important in medicine - especially when it comes to recognizing zebras and things that just don't 'quite fit'.   Like if some adult was unfortunate enough to have me as their doctor, and was having chest pain (which actually did happen on an airplane, God help them...I'm embarrassed to admit that I began thinking 'I wonder if they have sickle cell' before I realized that it's probably not the first thing I should think about when a 75 yo has chest pain.....), I'd be like EKG, basic labs and 'MONA BASH' and if that didn't work, they'd be SOL.  But give me a baby decompensating with b/l pneumos, effusions and HIE and I'm in my element.

Unless you go to a very high volume pediatric place,  you can't be expected to recognize this stuff, and all you should probably do is stabilize and call/transfer to a place that has a PICU.  It's just fun to think about! In the Pedi world, I think people would all rather be called a little early rather than a little late.  An adult cardiology consult would probably bite your head off if you called them without a basic workup, while a pedi cardiologist is likely to thank you for calling them early and come up with a plan of action.  

 

Well sometimes. I've been chewed out before.