a world of trouble…

The case.

A 3 week old infant is bought into your ED late at night. She is febrile and looks incredibly unwell. Her parents report a 36 hour history of increasing vomiting and poor oral intake. She has not had a wet nappy for 12 hours or so and the parents now report a fever of 39.5*C.

She was born at 39 weeks gestation following an unremarkable pregnancy and delivery. They were only in hospital for 2 days as everything was going so well…..

When you approach this child in resus, you immediately identify that she is in a whole world of trouble. She is flat and listless, tachypnoeic at 70/min (with moderate work of breathing) and tachycardic at 204 bpm. Her capillary return is 5-6 seconds and her skin is mottled. Her abdomen is quite obviously distended.

Amongst the flurry of activity at the bedside the following x-ray is taken….

SickSickInfant

What’s going on here ?
What are your differentials ??
What are you going to do next ???

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sweet & sour…

The case.

A 7 year old boy presents to your ED with a 3-4 day history of fevers, nausea and vomiting. There is some associated non-specific abdominal pain. He has a history of Type 1 Diabetes Mellitus. His blood glucose at triage is reading ‘HI’ and his finger-prick ketones are 6.4 mmol/L. He is therefore taken through to your resus bay, where you achieve IV access and get the following set of results…

BloodGas

EUCs

How do you approach this child ?
What are your principles of management ??
Would your approach be different if he was 37 years old ??? Continue reading

a twisting tale…

the case.

It’s night shift & you’ve received handover of an entire department. You plug on and start chipping away at the waiting-list that doesn’t seem ever get any shorter….

At 3am your nursing staff alert you to an 11 year old female who just isn’t getting any better. She was admitted under Paediatrics on the evening shift with 24 hours of vomiting (no diarrhoea) & had failed her trial of fluid. Whilst she is waiting for a paediatric ward bed she has continued to vomit a further 8-10 times and is complaining of severe epigastric pain. She had used up all her available antiemetics and analgesics on her medication chart…

She looks miserable, crying in pain and clutching at her abdomen. She is slightly tachycardic (otherwise normal observations). Her abdomen is non-distended but exquisitely tender with percussion tenderness and rebound. She has reduced bowels sounds. There is a scar in her RIF indicating a previous open appendicectomy ( ~18 months earlier).

You review her bloods (WCC 16, otherwise unremarkable) and her urinalysis is normal.

Despite further boluses of morphine, she continues to vomit and complain of severe pain….so, you order an abdominal xray.

IMG_1870

What’s going on here ?
What are you going to do now ??

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a troublesome tachycardia

The Case.

An 11 year old boy is bought to ED by his mother on a busy weekday evening. Mum reports that he has been ‘a little bit off’ over the past 24 hours, in particular he’s not keeping down his food or fluids. She is also worried about his colour, stating ‘he looks a little pale and sweaty’.

You find him a little wheezy on auscultation, with room air saturations of 93%. Of concern is his pulse rate of greater than 150 per minute.

This is his ECG…

What’s your interpretation ?
What would you do next ??

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