GRUMPY AND LETHARGIC, Carol Moore, 12, arrives at your emergency department with her mother. Mrs. Moore says that Carol had a mild case of the flu a week ago and seemed to be recovering. But yesterday, she vomited repeatedly and started sleeping a lot, waking up very irritable. As you escort Carol to a stretcher, she starts screaming and resists being examined.
What's the situation?
Mrs. Moore tells you that Carol can't swallow pills, so she took chewable aspirin for her fever during the flu. You take Carol's vital signs: respirations, 24; pulse, 110; and temperature, 980 F (36.70 Q. Carol is disoriented but follows commands, her pupillary reaction is brisk, and her oculocephalic reaction is normal. You see no evidence of jaundice.
What's your assessment?
Based on Carol's history and signs and symptoms, you suspect Reye's syndrome, characterized by acute encephalopathy and liver failure. It can rapidly progress to coma and death.
The classic scenario is a child who's taken aspirin after a viral illness during the winter-but Reye's syndrome can affect anyone at any time of year, with or without aspirin use. The lethargy and personality changes that occur early in Reye's syndrome are caused by impaired neurologic function secondary to cerebral edema.
Treatment is primarily supportive. Your top priority is to address the cerebral edema and protect Carol from permanent neurologic damage.
What must you do immediately?
Carol is breathing on her own, so you administer 4 liters/minute of supplemental oxygen via nasal cannula and attach a pulse oximetry probe to her finger so you can monitor her SPO^sub 2^ Start an intravenous infusion of 10% dextrose in 0.9% sodium chloride solution: Hypoglycemia is common in Reye's syndrome. Draw blood for liver function tests, coagulation studies, blood glucose level, and routine chemistries. Also obtain a blood specimen to check Carol's serum salicylate level. Prepare Carol for a thorough neurologic examination, lumbar puncture, and cerebrospinal fluid (CSF) analysis to rule out other infections, such as encephalitis and meningitis. In some cases, a liver biopsy may be ordered for a definitive diagnosis. Obtain a more in-depth health history from Mrs. Moore.
Abnormal lab values include aspartate aminotransferase and alanine aminotransferase of 200 units/liter (normal is 0 to 40 units/liter), low blood glucose, prolonged prothrombin and partial thromboplastin times, elevated blood urea nitrogen and creatinine, and elevated serum ammonia. The CSF analysis rules out other infections.
What should be done later?
Carol is admitted to the pediatric intensive care unit, where her neurologic status and serum lab studies will be closely monitored. Carol will receive corticosteroids to reduce brain swelling. She may receive small amounts of insulin to increase glucose metabolism and vitamin K to aid in coagulation. If her condition worsens, she may need to be intubated and mechanically ventilated.
Carol is discharged home 10 days later with no permanent neurologic damage. Explain to Mrs. Moore that children under age 19 shouldn't take aspirin or other products containing salicylates during a febrile illness. Inform her that antinausea and cold medications may contain salicylates.
Advise her to check with Carol's health care provider before giving any medication when Carol is feverish. She can also contact the National Reye's Syndrome Foundation, Inc., at 1-800-233-7393 for more information or visit its Web site at http://www.bright.net/~reyessyn.
BY TERRY LEE DOIRE, RN,C, BSN
Nurse-Manager, Labor and Delivery Unit * Baptist Medical Center * Jacksonville, Fla. Adjunct Instructor * Florida Community College at Jacksonville * Jacksonville * Jacksonville, Fla.
Copyright Springhouse Corporation Dec 1999
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