Lab case 74

A 14 year old female is brought in to your ED on a priority one by ambulance. She has had a one week history of vomiting and diarrhoea.

On examination:

Obtunded

extensor posturing

BP 40 systolic

PR 120/min

  1. What are your key initial steps?

Her blood results:

Na  119   (137-145 mmol/l)

K  > 8  (3.5-5 mmol/l)

Cl   87   (99-111 mmol/l)

HCO3  14  (24+-2 mmol/l)

Urea   25.4   (3-8 mmol/l)

Creat   314   (30-80 umol/l)

BSL 1.9  (4-6 mmol/l)

2. Describe and interpret the blood results

3. What clinical features would you look for to confirm your diagnosis?

4. What are your treatment priorities?

Thank you SETU for this great case

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5 thoughts on “Lab case 74

  1. 1. Establish reliable i.v. access, if not possible due to vascular collapse quickly go for i.o. Put on monitors and consider early intubation. Obtain bedside glucose measurement. Arterial blood gas, ECG, CBC and possibly urine samples.
    2. Severe hyponatremia, severe hyperkalemia, hypochloremia, low bicarbonate, hyperuricemia, severe creatinine elevation, severe hypoglycemia.
    3. GCS score. Low urine output. Presence of ketones in urine. CT head.
    4. Glycemic control with 100 ml D50W per i.o. or peripheral i.v. before central access is established. Followed by infusion and close monitoring of glucose levels. Would consider Mannitol and Decadron for cerebral edema. Arrange PICU care.

    Hypoglycemic coma with multiple organ dysfunction following Rota viral gastroenteritis.

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    • Thanks for the comment jan. Can you infer anything else from the blood results?

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      • possible adrenal insufficiency. high K low Na low glucose. AG 18, hco3 14: lactic acidosis secondary to poor perfusion. altered mental status 2o hyponatremia and hypoglycaemia & hypotension. suspect primary underlying sepsis. possibly even friedrich waterhouse .

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        • o no please ignore that, i did this one already. my bad.

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  2. Not really sure about fluid resuscitation in this case to be honest. Gut instinct would have me going for aggressive fluid resus early on to achieve euvolemia and limit end organ injury but not really sure how that would play with BSL correction.

    Thanks for any insights and relevant literature!

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