Problem Rounds

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Problem Rounds 7/20/06
10 month old baby not waking up
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CC not waking up HPI 10 mo female in USH
until 3 days PTA when got tylenol for a fever
(98.5- unsure but felt warm). Runny nose that
had developed over the week and small cough.
That day she was in the shower- mother holding
hands when she slipped and bumped R eye area.
Took to PMD right away and he said she was normal
and gave a cream that started with a B for
small cut above eye. No LOC, pt acting normal,
playful, eating well, slept fine 2 days PTA
acting weird She did not want to take food or
milk. Ate one gerber and 3times 4oz of poweraid
mother thought she may have sore throat. Felt
warm temp 102. Called OSH talked to unknown
person and told normal. No V/D. UOP the same.
Cont with URI. More sleepy, not as playful.

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HPI Continued 1 day PTA not want to take
anything. Managed to get ½ bottle of power aid
down her entire day (?32 ounce bottle). No food
or milk. Gave tylenol for fever (thermometer
broke). Slept most of day- very sleepy. Put to
sleep around 730 pm (last ate 630 pm). Last
UOP 6 pm (3x that day decreased from nml 6).
Mother got shirt out of room at 130 am and pt
asleep and nml. On DOA (pt normally sleep 730
pm 8 am), around 10am brother asked where she
was and mother went to check on her. She was
flat in the crib (no blanket on her, but in crib
no AC, windows closed and fan on in the hallway,
on 2nd floor of apt). She did not want her
bottle, was limp, breathing fast. Mom called
911. Pale with black under eye. No seizure
activity, no fall. No meds in house besides
cough medicine, not blue, not stop breathing with
mother. Brother sick with fever, cough, cold.
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HPI Continued EMS called 1036 Arrived 1041
found supine on floor (mother told to place pt on
floor). CC Resp Distress. No N/V. No obv
trauma. Assist vent via BVM and removed
clothing. Tylenol given. Temp ?105? (cannot
tell if paramedic took or if mother it says
mother reported that temp- mom denies reporting
that temp). 1045am HR 250 RR 4 O2 Sat
77 on RA 1050am HR 260 RR32 O2 Sat
98 Glucose 93
GCS 9 (E4/M4/V1) 1057am 74/50 HR 240 RR
35 GCS 6 (E4/M1/V1) last
vitals time arrived at PER
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Take a moment to consider your differential
diagnosis
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WCH ED Vitals 74/56 HR 200 RR 35 Temp gt107
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PE Cont Spont breathing in PER. General
lying on gurney, unresponsive, non rebreather in
place Hydration dry mucus membranes Skin cool,
mottled Head NCAT, sunken AF Eyes Sunken,
yellow d/c and conjunctivitis to L eye, eyes
staring straight, constrict sluggish
3mm-1/5mm E/N/T dried clear rhinorrhea Neck
Supple Lungs CTA-B CV tachy gt200 regular, CR
4 secs, palp thready B femoral pulses Abd soft,
BS, no mass GU tanner I female, large amount
foul smelling, green stool EXT cool,
mottled Neuro unresponsive, not withdraw to
pain, UE tensing intermittently, LE flacid
thoughout, biting
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Labs Highlights 7.22/ 27/ 361/ 10 BD 15.4
Na 161 K 2.7 Cl 130 Ica 4.1
(from VBG) Na 161 K 2.5 Cl 130
Bicarb 9 Glucose 75 Mg 2.5 Ca
6.8 Phos 5.7 BUN 42 Creat
1.1 UA 20.3 AP 110 TP 5.7
Alb 3.9 TB 0.1 DB lt0.1 CK
234 LDH 449 AST 67 ALT 22
Fibrinogen 420 D dimer 1324
PT 18.1 INR 1.5 PTT 34.6
Lactate 1.7 WBC 8.2 H/H 9.4 /
28.8 Plts 184 72P/18L/8M 10-24bands
ESR 57 UA 6.5/ mod blood/ 100 prot/
1012/ lt250 reducing subst/ RBC 0-1
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PMH None PSHx None BHx FT NSVD no
complications home in 2 days. Meds Cream with
B Tylenol 0.8 ml PMD has at
Outside NKDA Immunizations UTD card
(2,4,6mo) FHx Mom 19, dad 23, brother 3 and
pt 10mo no medical problems in family SHx
Lives with family in 2 b apt (2 floors), denies
ETOH, Tob, Drugs, Viol, Guns, Pets, JEHOVAH
WITNESS Development says MaMa, Papa to anybody
uses both hands to grab objects equally
transfers makes noises that sound like words-
babbles pulls to stand, sat at 6mo alone Diet
Similac, 5 jars of gerber a day
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Take a moment to consider your differential
diagnosis
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• In our ER
• Unable to get IV, so IO placed then later Central
  Line placed
• Cooling measures, Tylenol
• Pt with starring B eyes with body stiffness
  given Ativan 0.8 mg IO, loaded Phosphenytoin 160
  mg IO
• Intubated (given Rocuronium, ativan)
• Cefotaxime, Vancomycin, Acyclovir started
• Dopamine started
• NS bolus 20cc/kg x 4

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Take a moment to consider your differential
diagnosis
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Studies EEG x3- diffuse slowing
MRI hypoxic encephalopathy diffuse
Echo normal
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Take a moment to consider your differential
diagnosis
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• Findings
• Heat Stroke (gt107 temp)
• Dehydration 15
• Shock- low BP
• Resp Arrest
• Intubate
• Seizures (cont with once in unit)
• Electrolyte disturbances (hypernatremia,
  hypokalemia, hypocalcemia, hypercholremia)
• Metabolic acidosis
• Anemia
• Presumed sepsis
• Hypoxic injury to brain

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• Thanks to Natasha Rodgers who provided this
  excellent write up.