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An acutely collapsed patient
  1. Abhinav Singh1,
  2. Arnold Dunga2,
  3. Myooren Wimalendra2
  1. 1Royal Free Hospital, London, UK
  2. 2Department of Paediatrics, The Derriford Hospital, Plymouth, Devon, UK
  1. Correspondence to Dr Myooren Wimalendra, Department of Paediatrics, The Derriford Hospital, Derriford Road, Plymouth, Devon PL6 8DH, UK; mwimalendra{at}

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A previously well 14-year-old boy presented with a 3-day history of diarrhoea and vomiting with a background of week-long coryzal symptoms. On arrival he was confused, tachycardic, tachypneic and hypotensive. His blood sugar in the ambulance was 3.0 mmol/L. In total, 15 mL/kg 0.9% saline bolus and 250 mL of 5% dextrose were given via intraosseous access in the emergency department. The patient was pyrexial with an elevated C reactive protein (63 mg/L), hence, prophylactic ceftriaxone (4 g intravenous) was commenced. His first venous blood gas showed:

pH 7.09, pCO2 5.28 kPa, PO2 4.61 kPa, BE −16.6, HCO3 11.4 mmol/L

Potassium 7.1 mmol/L, sodium 116 mmol/L, glucose 8.8 mmol/L, lactate 7.4 mmol/L, urea 11.9 mmol/L.


1. What is the most likely diagnosis?

  1. Diabetic ketoacidosis

  2. Non-ketotic hyperosmolar state

  3. Renal failure

  4. Pancreatitis

  5. Addisonian crisis

2. After aggressive fluid resuscitation, what is the next step in this patient's management?

  1. Inotropic support and antibiotics

  2. Parenteral hydrocortisone and …

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  • Contributors MW and AD managed the patient. AS wrote the initial draft. All authors contributed to the completion of the final manuscript.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.