Case 1: Vomiting and Ventricular Arrhythmia in a 2-year-old Girl

1. Benjamin H. Gern, MD* 2. Amit Mehta, MD* 3. Amy N. McCammond, MD* 4. Kathryn W. Holmes, MD, MPH* 5. Judith A. Guzman-Cottrill, DO* 1. *Department of Pediatrics, Oregon Health and Science University, Portland, OR A 2-year-old girl presents to an urgent care clinic with a 1-day history of nonbloody, nonbilious vomiting, intolerance of oral intake, and decreased urine output. There is no present history of fever, abdominal pain, diarrhea, cough, trauma, or travel. Two weeks before presentation, she recovered from a febrile illness. In urgent care, she is treated with two 20-mL/kg normal saline boluses and intravenous ondansetron and is admitted to the general ward for monitoring and intravenous fluid rehydration. On hospital admission she is afebrile, and vital signs include a heart rate of 106 beat/min and elevated blood pressure of 121/69 mm Hg. She is sleeping but awakens appropriately with examination. The rest of her physical examination findings are normal. Her complete blood cell count shows a white blood cell count of 18,800/μL (× 109/L), with 85.1% neutrophils; a hemoglobin level of 10.5 g/dL (105 g/L); and a platelet count of 451×103/μL (451×109/L). A comprehensive metabolic panel is notable for an aspartate aminotransferase level of 104 U/L (1.74 μkat/L) (reference range, 5–43 U/L [0.08–0.72 μkat/L]) but is otherwise normal (including normal electrolyte levels). Four hours later, the patient is found pulseless and apneic. There …