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You are seeing a 5 year old fully immunized patient with 2 weeks of new onset bedwetting, 3 days of cough and fever, and 2 days of increased work of breathing. Initial POC labs are significant for a blood sugar of 450 and a pH of 7.11, Na 130, K 3.4. You start a 20 cc/kg NS bolus and send a full set of labs. The patient is complaining of headache and is lethargic initially, becoming increasingly obtunded over the first half hour in the ED.
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November 21, 2017 at 6:54 pm
E) Give mannitol 0.25-0.5 gm/kg IV
This patient is in new onset DKA and is showing signs of cerebral edema. Although the patient has had cough and fever (likely a viral URI that may have triggered the DKA episode), meningitis as cause of altered mental status in this immunized patient is less likely than cerebral edema, and lumbar puncture is not recommended without imaging & funduscopic exam to rule out increased ICP. Mannitol is the best treatment for acutely worsening cerebral edema, and should be given empirically when increased ICP is suspected, even before obtaining CT.