CAH with adrenal crisis

This case is written by Dr. Quang Ngo from McMaster University. Dr. Ngo is a pediatric emergency physician in Hamilton, ON and one of the advisory board members at EMSimCases.

Why it Matters

This cases highlights three crucial management steps for a toxic neonate:

  • Maintaining a broad differential diagnosis (including hypoglycemia, sepsis, metabolic/cardiac conditions)
  • Consideration of hypoglycemia as a cause or consequence of a toxic neonate
  • Treatment of hypoglycemia in a neonate

This case also reviews management specific to congenital adrenal hyperplasia:

  • Recognition of laboratory abnormalities associated with adrenal crisis and initiation of steroid treatment

Clinical Vignette

A 1 week old neonate is brought to the emergency department because his parents are worried that he’s been vomiting and not keeping his feeds down. After he vomited his last feed, his parents noted he was quite lethargic and felt cold. His mom states he’s been increasingly sleepy since discharge and she’s been needing to wake him to feed. In between feeding, he sleeps and doesn’t “act like my other 2 kids did at that age.” The team is called to assess this patient urgently after being triaged because the nurse felt the patient looked unwell.

Case Summary

A lethargic 1 week old presents from home after recurrent emesis and progressive sleepiness. He is hypovolemic, hypothermic, and hypoglycemic. If his hypoglycemia is not quickly corrected, he begins to seize and will continue to do so until the team gives glucose. If they do not, the patient will go on to have a VF arrest. If the team identifies and treats the hypoglycemia, orders blood work, and fluid resuscitates the child, they receive blood results demonstrating hyperkalemia and hyponatremia. If they correctly identify and treat the patient as a possible adrenal crisis, the neonate is safely transferred to the PICU. If they fail to treat the hyperkalemia or fail to administer steroids, the patient will have a VF arrest.

Download the case here: CAH Case

ECG for case found here:

Hyperkalemia peaked T waves

(ECG source:

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