Zuhra is a 3-month-old girl who was brought to the emergency department with a history of
vomiting and diarrhea with poor PO intake. You note that Zuhra appears listless; she is lying
on the bed and does not respond to her parents. She is breathing rapidly without retractions or
respiratory distress. Her color appears mottled.
1. What is your initial impression of the child’s condition based on your general
2. Does this infant require immediate intervention? If so, what intervention(s) is(are)
You administer high-flow oxygen and proceed with your primary assessment. You obtain the
following vital signs for Zurha: HR 210bpm, RR 50, BP 60/43 and axillary temp is 36.1°C.
The pulse oximeter is not picking up the pulse consistently – when a reading is obtained it is
99% to 100%. You palpate weak brachial and femoral pulses, but you cannot palpate distal
pulses. Heart sounds are normal. Extremities are cool to touch and mottled below the elbows
and knees. Capillary refill time in the foot is >5 seconds. Auscultation reveals clear lungs with
good distal air entry bilaterally. During the assessment, Zurha moans occasionally but
otherwise has little response to verbal or painful stimulation.
3. How would you categorize Zurha’s condition?
4. Based on the last blood pressure taken, would you consider Zurha hypotensive?
Your colleagues try to establish vascular access while you obtain additional history
information. Parents report the following: Zurha has had “nearly continuous vomiting and
diarrhea” during the previous 8 hours. They are uncertain if she has urinated during this time
because her diapers have been filled with watery diarrhea. She has no allergies and is not
receiving any medications. Her PMH is unremarkable. She took an ounce of fluid about an
hour ago. Events leading to her admittance to the ED are as follows: Zurha was well until
yesterday when she initially started having episodes of vomiting and then a few hours later
began having watery diarrhea. Her vomiting has subsided, but she is not taking clear liquids
well and her diarrhea is worse today. There is no hx of fever, and no one else in the family is
Zurha has reduced skin turgor without skin rash except for erythema of the diaper area. The
abdomen is soft with the liver at the costal margin. Her fontanel is sunken.
5. After vascular access is obtained, you are required to deliver 20 mL/kg bolus of Normal
Saline. Zurha’s recent weight is 5.4 kg.
a) Based on Zurha’s weight of 5.4 kg, how much fluid will you administer?
b) The bolus needs to be delivered over 15 minutes, show your calculations
Zurha’s VS are now: HR 195-200 bpm; respiratory rate remains at 50, blood pressure is 66/42,
and SpO2 is 100%. Zurha appears a bit more responsive, but the distal pulses are still not
palpable. Capillary refill remains prolonged.
6. Based on your reassessment, what are the key indicators that lead you to determine that
Zurha requires another bolus