Start intravenous antibiotics

You decide to start intravenous antibiotics because Charlie is clearly very unwell and this will cover infectious causes. You prescribe ceftriaxone. Because of the vomiting you keep Charlie ‘nil by mouth’, and ask the nurses to site a naso-gastric tube.

You explain the plan to the nursing staff and to the mother. Charlie’s mother is pleased that this problem is being taken seriously but wants to take her home as soon as she is better. Charlie is admitted to the ward and intravenous 0.9% NaCl with 5% glucose is started. A naso-gastric tube is inserted and large amounts of green fluid is aspirated.You request a CT scan of the abdoman.

Intermittently Charlie appears to develop spasms of pain that last for 5-10 minutes before abating. At one stage the nurses ask you if they need to call the arrest team again because she has become so pale and lifeless, but she has a good pulse and when you see her she has recovered. You prescribe some intravenous paracetamol.

In the evening you review her. She has not yet had the CT scan. The nurses say that she has passed a blood, mucousy stool. Charlie is now less alert than before and not interested in her surroundings. She is pale with a capillary refill time of 3-4 seconds. HR is 185/min, RR 45/min.

Meanwhile some more results have come back, sent by a colleague earlier.

Hb                                           89        g/L
Wcc                                        15.1 x 10⁹/L
Plats                                        474 x 10⁹/L
Urea                                        8.2 mmol/L
Na                                           145 mmol/L
K                                             3.7 mmol/L
Creat                                       41 micromol/L
CRP                                        38 mg/L
Ca                                            2.35 mmol/L
PO₄                                         0.57 mmol/L
Ferritin                                   72 microg/L
Vitamin B₁₂                             550 nanog/L
Folate                                     81 microg/L
Vitamin D                               <10 iU/L
Alkaline phosphatase854 iU/L

When you contact the CT scanning room, you find out that they are running behind schedule and will not be able to scan her until the morning. They suggest an ultrasound instead.