Age: 1.01
Sex: M
Vaccine: HEPA, MMR, PNC13, VARCEL
Symptoms: Listless, Livedo reticularis, Lumbar puncture, Meningitis, Mental status changes
Clinical narrative: CHIEF COMPLAINT:  He presents here as a 12 month old that was brought in by mother, carried in from triage to shock room 2, lethargic and listless. HISTORY OF PRESENT ILLNESS:  The patient, according to mother's history, was exposed to several family members who have had URI symptoms over the last 24 hours and this morning he slept more than usual, walking up around 10:30 this morning, and was found to be lethargic.  The patient was carried into shock room 2.  Further history was not available. PAST MEDICAL HISTORY AND SURGICAL HISTORY:  Negative. ALLERGIES:  Negative. MEDICATIONS:  Currently negative. REVIEW OF SYSTEMS:  As per HPI; otherwise, all negative. PHYSICAL EXAMINATION: General:  The patient was lethargic, listless, and unremarkable. HEENT:  His oropharynx was clear.  He did not have any tongue lacerations or abrasions.  He had moist mucous membranes. Neck:  Supple.  I did not appreciate any obvious lymphadenopathy or meningeal signs. Lungs:  Clear on auscultation.  He had moderate accessory muscle use with intercostal retractions. Abdomen:  Soft.  I did not appreciate any distention or signs of trauma. Extremities:  The lower extremity exam was cold to touch.  He had poor perfusion.  He was mottled. Neurologic:  The patient had positive nystagmus and almost exhibited tonic-clonic-like activity. EMERGENCY DEPARTMENT COURSE:  Immediately, we decided to intubate this patient to maintain a definitive airway.  Using a 4.5 endotracheal tube that was uncuffed, I proceeded with intubation. A peripheral IV was inserted immediately by our nurse.  I used 15 mg of IV succinylcholine with a dosing determined using a weight based scale.  We believed the patient was anywhere from 10 to 12 kg. Once the patient was adequately paralyzed, I was able to successfully intubate this patient.  He had positive end-tidal CO2 and condensation in the tube.  He had blood work including a CBC, a blood culture, and a BMET.  I had the patient transferred immediately to head CT which showed evidence of chronic maxillary sinusitis with no evidence of mass effect. When the patient returned back to the emergency room into shock room 2, I proceeded with spinal tap.  Given the emergency situation, we did not have a chance to consent mother who was not immediately available.  We went ahead and proceeded with the procedure.  I was able to successfully perform a spinal tap using his pelvic crests as my landmarks.  The entire procedure was performed under sterile conditions.  The back was cleaned using iodine applied in circular fashion x3.  Using the pediatric LP tray, and the spinal needle that was within the tray, I used the L3-L4 interspace to access the subarachnoid space.  I was able to collect 3 tubes of CSF, at least 2 mL each, and these were sent for studies including HSV, PCR.  We went ahead and ordered antibiotics including Rocephin 100 mg per kg IV. Laboratories returned with a white count 30.7, hemoglobin 14.0, platelet count 344.  Sodium 153, potassium 6.9, chloride 113, CO2 of 10, BUN 88, creatinine 1.15, calcium 7.2.  We are getting a BMET.  I have ordered IV glucose, D25 2 mL/kg.  A urine culture, and urinalysis, and a blood culture were ordered and pending.  Postintubation chest x-ray showed left-air space disease.  Right lung was clear.  Endotracheal tube appeared to be in satisfactory position.  Head CT did show evidence of chronic maxillary sinusitis. I spoke to Dr. from ICU and the patient will be transferred there in critical but stable condition.  He asked that we go ahead and give him vancomycin 20 mg/kg IV as well as Acyclovir 20 mg per/kg IV, and I will also order maintenance IV fluids after receiving initial 200-mL normal saline bolus.  We also gave him an ampule of calcium gluconate for his hypocalcemia. IMPRESSION: 1.   Mental status changes. 2.   Acute meningitis. 3.   Sepsis syndrome. DISPOSITION:  To ICU in critical but stable condition. CRITICAL CARE TIME:  Exclusive of all procedures which included endotracheal intubation as well as spinal tape, greater than 60 minutes.