I'd like to hear your views on a difficult clinical case that ended poorly.
It concerns a 6 year old girl who presented really sick after a week of chickenpox. She was seen at our ED yesterday with a fever and was evaluated, given anti-pyretics and sent home. She returned today in extremis, hypoglycaemic, hyponatraemic, hyperkalaemic, acidotic and a lactate of 8 mol/L with renal impairment. She was covered head to toe in some green lotion, believed to be Camomile lotion, with Russian language writing on the bottle.
2 x 24G IV were placed - her peripheries were ice cold and her BP unrecordable.
She was fluid resuscitated with 0.9% saline, given acyclovir, ceftriaxone, and flucloxacillin IV. Her high potassium was managed with calcium gluconate, and NaHCO3 and salbutamol nebs. The paediatricians were reluctant to give insulin dextrose (because of her initial hypoglycaemia) so that was held. She continued to deteriorate, her metabolic acidosis worsened. Peripheral dopamine was started and a Foley catheter was placed in her bladder. The retrieval team arrived and an IO needle was placed and an adrenaline infusion was started. A CVC placed in her left femoral vein but placement of an arterial line failed in both femoral arteries as the child was extravasating all of the fluid she received and becoming very oedematous. She underwent RSI with ketamine and rocuronium and keeping a MAP of around 50mmHg. She continued to deteriorate, lost her BP and arrested.
She was Rx with insulin IV pushes and CaCl via the CVC and had ROSC after a single shock (she went from PEA to VF). Her potassium failed to respond to pushes of insulin and further calcium and she experienced 3 further cardiac arrests.
Finally, she was transferred to the tertiary centre PICU for ECMO/CVVHD but died en route.
I work in a centre with no PICU and have a number of issues I'd like to discuss.
1) Leadership in these scenarios. Present in the room were myself (ED/ICU Consultant), the ICU Consultant and a Paediatric Consultant. The question of who leads these scenarios is something I find personally difficult. I am relatively inexperienced as a Consultant and I was working with 2 Consultants with more than 10-20 years more experience than I. How do you do this?
Do you agree a leader at the beginning and then go from there?
Does the ED Consultant always lead if other more experienced colleagues are present?
2) Management of hyperkalaemia in kids - I've not come across a cardiac arrest in a child 2ary to hyperkalaemia. How quickly to you run an infusion of insulin/dextrose? We were giving 2 units of insulin IV blouses and drew up an infusion of 0.1units/kg insulin with 5mL/kg of 10% dextrose. How quickly do you run this infusion? Over 10 mins, 30 mins?
I'm not certain.
3) Has anyone seen anything similar to this before?
Toxic shock on a background of chickenpox - we don't have a cause of death yet.
Blood culture results are still pending. Blood results were quite abnormal, with a CRP of 270, INR 3.5, APTR 3.2, and an unrecordable low fibrinogen.
I'd appreciate your observations on leadership when you're starting out as an attending/consultant & you're the least experienced of your grade in the room. Any FOAM resources you could point in my direction?
How do you manage life-threatening hyperkalaemia in septic kids in renal failure?
We have no PICU at our hospital and so no ability to filter kids for hyperK. How do you feel about peripheral pressors in kids?
Do you place IO needles as a quick means of starting pressors?
What's your preferred pressor/vasoactive medication for these kids?
I have so many questions about this case. Thanks for taking the time to read it.