Nail Biter

Patient of the day: 19 month old who was lethargic. She had a lot of other medical problems and had had an endoscopy yesterday. Since then she had been lethargic and vomiting brown. In the ED, she looked pretty bad...very lethargic, kind of hypotonic, pale. She got a LOT worse pretty quickly. PICU came down and we had probably 7-8 people around the bed for this one little girl. Her glucose finally got checked (somehow this order from when she first got into the ED had been overlooked) and it was 1. ONE! Glucose should be around 100, and below 40 is SCARY low. Hers was ONE. I have never seen anything that low, and I have no idea how she wasn't having seizures or how she wasn't dead yet. She was so dehydrated that they couldn't get an IV in, so they had to put an interosseous line in (basically punching a hole in her leg bone to run fluids directly into her bone marrow). She got some glucose which put her blood sugar at 187 and started looking better. She kept oscillating back and forth from looking a bit better to being really lethargic again. We never intubated her and she made it out of the ED to the PICU, but it was a REALLY scary situation. I hope she will end up doing ok. Lesson learned: always check a glucose on anyone with altered mental status...low glucose really can happen even when you're not expecting it!