A 7-year-old boy is brought to the Emergency Department with a 1-day history of worsening vomiting. Over the last few hours parents report that he has been much less responsive and is now not talking but only making moaning noises. He has had bedwetting over the last 2 weeks having previously been dry at night from age 3.On examination he is pale, dehydrated, making laboured respiratory effort, rate of breathing is 50/min. He is lying in his mother’s arms, opens his eyes when his name is called, movement is reduced but he will move his arm away from a painful stimulus.
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(a) Is there a need for any resuscitation intervention?
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Yes. Altered conscious level is potentially life threatening as impaired consciousness means that the airway can be compromised. If a partially conscious patient vomits they may aspirate
and risk respiratory arrest. Intervention to protect the airway includes positioning of the neck and chin and consider whether nasogastric tube should be placed to aspirate stomach contents.
Call anaesthetist as airway intubation may be needed.
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(b) What is the Glasgow Coma Score of this patient?
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Glasgow Coma Score (GCS) total 9:
• Eye opening 3 (to verbal command)
• Movement 4 (flexion with pain)
• Speech 2 (incomprehensible sounds)
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(c) What level of monitoring is required ?
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He needs high-dependency one-to-one monitoring to observe for any further deterioration which would require urgent resuscitation. He should be moved to a resuscitation room or high-dependency unit. Continuous physiological monitoring of oxygen saturation, ECG, pulse rate, is necessary. High-frequency measurement of blood pressure, pupil responses, GCS, temperature and fluid balance is needed.
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(d) Which of the following diagnoses is most likely? (1) Ingestion of poisonous drug/ chemical; (2) Intracerebral haemorrhage;(3) Meningitis; (4) Diabetic ketoacidosis; (5) Gastroenteritis.
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(4) Diabetic ketoacidosis is suggested by the pattern of breathing, which indicates metabolic acidosis, and the history of nocturnal enuresis.
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(e) What investigations should be performed urgently?
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Blood glucose, gas, ketones will confirm diabetic ketoacidosis: pH < 7.3, bicarbonate < 15, blood glucose > 11 mmol/L. Blood urea and electrolytes will help guide fluid management.
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(f) Describe the management over the next few hours
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• Intensive monitoring during correction of metabolic and fluid derangement with aim to restore pH, glucose, potassium and fluid balance.
• Intravenous insulin is started 1 hour after intravenous fluids to stop ketogenesis and gradually correct blood glucose.
• Monitor particularly for cerebral oedema which can present with bradycardia or headache.
