UW mistake? - brain

[ArchivalUser]

A 3-year-old boy is brought to the emergency department by his mother because he is lethargic and refuses to eat. His family recently arrived in the US as refugees from an African country. His mother hardly speaks English, and this has made history-taking very challenging. His temperature is 36.1C(97F), blood pressure is 90/60 mm Hg, pulse is 130/min, and respirations are 26/min. His height corresponds to the 38th percentile and his weight to the 5th percentile. He is lethargic and hypoactive. There is symmetrical edema of both feet. Painful, oral ulcers are observed. The patient is subsequently admitted to the hospital for rehydration and feeding. Which of the following is the best statement concerning the initial management of this patient?

A. Establish IV line and start IV hydration/feeding
B. Insert nasogastric tube and start hydration/feeding
C. Start high-calorie feeding
D. Start high-protein feeding
E. Start iron supplementation

[ArchivalUser]

b.

[ArchivalUser]

NG tube and hydration/feeding
he is a kwashiorkor needs the ng tube b/c you can't feed/hydrate him with his mental status. This is s/w usual and is similar to gastroschisis option for mild diarrhea dehydration on kids that are not tolerating PO...

[ArchivalUser]

Yes UW answer is bb, but don't you think his BP is low enough to give iv? How low can it go? Also he is lethargic and hypotonic. Urgent treatment is necessary?

[ArchivalUser]

was wrong here also...my knee jerk answer was A.

But B is the correct one.

[ArchivalUser]

90/60 on a 3 year old kid? nope
according to harriet lane according to his height he's at 75th percentile for systolic and 90th for diastolic.

[ArchivalUser]

bdj- how do you calculate 75th/90th percentile? tks

[ArchivalUser]

you rather do slow remember he's kwashiorkor if you load him with protein he becomes uremic...and careful with IV fluids as he's already hypervolemic...

[ArchivalUser]

brain I'm a pediatrician, so I know. You don't have to calculate that, i can tell you important thing here is that 90/60 is normal even in early teens (mine is 95/60 most of the time and I am no teen!)
So don't be worried about that. Kwashiorkor kids are somewhat irritable at baseline, and edema is b/c of hypoproteinemia. So you have to be careful also b/c as soon as you start giving them protein the other thing that will happen is that they will begin "suctioning" fluid from third space. Be careful with heart.
And meant hyperammonemia NOT uremic LOL just noticed it!