Thursday, September 6, 2007
4 year old girl, previously well, seen yesterday for cough and SOB x 1 day, nil fever. Impression was that of acute bronchitis, CXR normal, was discharged home with ventolin syrup. Represented to CE today for fit, started 45 mins ago. On examination, child was still in altered mental state, no obv fitting. Temp 38.4C HR 170 RR 40 BP stable SpO2 95% on RA. Child was in respiratory distress - retractions, tachypnoea and bilateral decreased in air entry and exp rhonchi ++. Initial management: face mask, nebulisation. History taken, no apparent fever detected by mother. child was sleeping all the way when she was suddenly in SOB, within minutes she was fitting (GTC). has been taking well orally prior to fit. During the 2 hours in CE, she did not respond very well to neb, still in resp distress. Hypocount taken 1 hour later was 1.8, 10% Dextrose was quickly given via bolus (5ml/kg). HR went up to 200 after the neb. ?myocarditis. ECG done - sinus rhythm. Sent for CXR - lung fields normal. cardio-thoracic ratio is 55%. ?globular in shape. She never regained to full consciousness, fitted again 2 hours after arrival, IV diazepam given. Quickly sent up to ICU. Blood results returned: WBC 40 ANC 38 Na 138 K 6.6 HCO3 13. Lessons learnt - any patient who comes in with AMS - differentials: CNS pathology (encephalitis/meningitis, intracranial bleed, SOL), sepsis, electrolyte imbalance, post-ictal drowsiness, hypoglycemia... What was worrying about her was that she never regain full consciousness after 2 hours, and her HR was high, and her hypocount became low. She was actually in sepsis, with involvement of the respiratory system, ?CVS system and CNS system. ?encephalitis ?myocarditis. Once you see a sick child, you'll never forget. Whatever it turned out to be, I hope she'll be fine...
