2 year old male who is unwell requiring resuscitation and further investigation

1. Abnormalities:

Vitals:   hypotension, tachycardia, tachypnoea, apyrexial

Severe acidosis – HAGMA

Total body K depletion (actual = 2.25)

Appropriate compensation

No additional acid base disorder

Elevated urea, normal Creatinine – pre renal

Elevated lactate – shock and hypoperfusion

Infection markers not significantly elevated

Normal glucose and mild elevation in ketones

2. Calculations:

Anion gap = Na – Cl – HCO3

Compensation = 1.5 X HCO3 + 8

K depletion = every 0.1 reduction in pH reduces total body K by 0.5

Delta gap = AG-12/ 24-HCO3

3. Causes – Unlikely to be renal failure, DKA, sepsis (although must remain in differential diagnosis until excluded)

Likely to be lactic acidosis – must exclude toxins

4. Treatment priorities:

attention to airway and oxygenation

iv access – fluid resuscitation and vasopressors if required

Replace K – based on serial K measurements

HCO3 – with caution, based on serial gasses

monitor urine output

Consider antibiotics

As it turns out, the mum of this child had been feeding him almond milk exclusively for the past two months. We considered Cyanide toxicity as a cause. The child was admitted by Paediatrics, treated until acid base status and clinical picture resolved and discharged home. Infection was not thought to be a cause. The almond milk was stopped. A full metabolic screen was negative and the child was completed symptom free at 2 month checkup. The Cyanide testing was negative as well?????