A 10-year-old boy with diabetic ketoacidosis deteriorates 6 hours after starting treatment: headache, irritability, heart rate 150/min, blood pressure 110/85 mmHg with a narrowed pulse pressure, and a newly dilated right pupil. CT scanning is not immediately available. What should be done now?

• A Administer intravenous furosemide 1 mg/kg to promote free water excretion
• B Obtain an urgent lumbar puncture to exclude meningitis
• C Give a 20 mL/kg normal saline bolus and repeat the sodium level
• D Give intravenous mannitol 0.5 to 1 g/kg over 10 to 15 minutes ✓

Explanation

Headache, irritability, bradycardia with hypertension, and a focal pupillary change during DKA treatment indicate cerebral edema with impending herniation. Treatment must start immediately, before imaging, with mannitol 0.5 to 1 g/kg IV or 3% hypertonic saline, head elevation, and reduction of fluid rates. Delaying therapy for a CT scan costs brain tissue. D lumbar puncture is catastrophic with raised intracranial pressure, and more fluid worsens edema.

Reference: Nelson Textbook of Pediatrics, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.