This is a critically unwell child requiring simultaneous resuscitation and assessment to identify the underlying cause with appropriate interventions.

1. List the acid base abnormalities

Severe mixed acidosis

High anion gap metabolic acidosis (HAGMA) – anion gap = 22, HCO3 = 11, with very high lactate level

Respiratory acidosis, expected CO2 = 24, actual = 37 (within limitations of VBG) with significant hypoventilation

Severe hypoglycaemia, requiring glucose iv

Depletion of total body Potassium (in view of acidosis, actual Potassium closer to 2)

2. DDx

Sepsis

Toxins – sulphonylureas, metformin, (snake bite, scorpion sting)

Seizures

Hypoperfusion/ shock

trauma – head injury, other

3. Normal Vital signs for a two year old:

BP = 80/40 – 100/70

PR = 100 – 150/min

T = 36.5 – 37.5

RR = 25-40

This child is hypotensive, tachycardic and hypoventilating

4. Time critical emergency.

Resuscitation Bay

Team Approach

Assume team leadership and allocate roles

Clear closed loop communication

Ensure rest of department handed over to senior colleague

Continue Oxygen as given

No immediate airway compromise, however prepare for RSI in event of deterioration or inadequate response to initial therapy. ivi access, 3 attempts, then Intra Osseus in proximal Tibia.

Glucose – bolus of 3 ml/kg of 10% Dextrose, repeated X 3

Fluids – bolus of 10 ml/kg of 0.9% Saline, repeated X 3

Seizure control – 0.1 ml/kg midazolam, repeat X 3

Antibiotics – 50 ml/kg Ceftriaxone as indicated

Allocate senior staff member to be with grand parents (explain events), attempt to contact parents