Three-year-old with acute gastroenteritis and lethargy
A 3-year-old girl weighing 14 kg is brought to the emergency department with 2 days of vomiting and watery diarrhea. She has had no urine output for 10 hours. She is lethargic but arousable, with dry mucous membranes, sunken eyes, and skin tenting. Vital signs: HR 150 beats/min, RR 40 breaths/min, BP 88/50 mm Hg, SpO2 98% on room air, temperature 38.1°C. Capillary refill is 3 seconds, extremities are cool, and pulses are weak. Point-of-care glucose is 58 mg/dL. Venous sodium is 132 mEq/L, potassium 3.2 mEq/L, bicarbonate 12 mEq/L, and chloride 100 mEq/L. Her weight is down 1.2 kg from 2 weeks ago. The team has established a 22-gauge IV. No blood is in the stool, and the abdomen is soft.
1. What is the physiologic state, and what are the first five actions?
Read the worked answer
She is in hypovolemic shock with hypoglycemia and metabolic acidosis, likely from acute gastroenteritis. The first actions are: call for help and apply cardiac and pulse oximetry monitoring; ensure airway and breathing while giving high-flow oxygen if needed; obtain IV access and begin an isotonic crystalloid bolus; check and treat glucose immediately; and obtain cultures and labs while reassessing perfusion. Do not give oral fluids. Because she is febrile and shocked, consider sepsis and obtain blood cultures before antibiotics, but do not delay resuscitation. Assess mental status, pulses, capillary refill, blood pressure, and urine output after each intervention. Place a urinary catheter to monitor output. This is not simple dehydration; the combination of lethargy, weak pulses, hypotension, and acidosis defines shock and requires rapid, repeated reassessment.
2. Calculate the fluid bolus and dextrose dose. How would you reassess after each intervention?
Read the worked answer
For 14 kg, an isotonic crystalloid bolus of 20 mL/kg is 280 mL of 0.9% sodium chloride, given rapidly and reassessed. Give dextrose for glucose 58 mg/dL: D10W at 5 mL/kg = 70 mL IV, or D25W at 2 mL/kg = 28 mL, followed by a glucose recheck in 15 minutes. Reassess after the bolus: heart rate, blood pressure, capillary refill, mental status, liver size, and lung sounds. If shock persists, give a second bolus of 10–20 mL/kg and reassess; avoid stacking boluses without reassessment. Do not give potassium until urine output is established. Recheck glucose, sodium, and acid-base status. If perfusion does not improve after 40–60 mL/kg or she needs vasopressors, escalate to pediatric critical care. Document each bolus, the response, and the glucose recheck.
3. Which complications or errors would you watch for during resuscitation?
Read the worked answer
Watch for over-resuscitation with pulmonary edema, hepatomegaly, and worsening respiratory distress; hyponatremia from hypotonic maintenance fluids; recurrence of hypoglycemia; and hypokalemia after acidosis corrects. Avoid giving potassium before urine output is confirmed. Avoid rapid correction of sodium; her sodium is only mildly low. Reassess mental status because persistent lethargy may reflect continuing shock, hypoglycemia, or cerebral edema. Monitor urine output and obtain a repeat glucose after dextrose. If she remains acidotic and shocked, consider sepsis, cardiac dysfunction, or another diagnosis. Escalate early to critical care if she needs multiple boluses, vasopressors, or has altered mental status. Good resuscitation is not just calculating the first bolus; it is the repeated reassessment and stopping or escalating based on the response.