5 year-old female with HPN dependence secondary to meconium pseudo-cyst develops acute agitation, headaches and vomiting immediately upon infusing HPN, which is a new batch from that was delivered yesterday. Of note, there have been no recent HPN prescription changes. Patient lives with parents in a single room apartment in a housing shelter.
In the emergency department, her sodium is 176 mmol/L (high) and blood glucose is normal. Head CT shows several new intraparynchemal hemorrhages. What is the next step?
A. Reassurance, discharge to home, check outpatient labs in 1-2 weeks.
B. Check blood cultures. Start broad spectrum IV antibiotics. Run HPN solution from home.
C. Correct hypernatremia with IV fluids slowly. Testing electrolyte contents of HPN bag.
D. Consult child protective team for intentional salt poisoning. Put child into immediate hospital custody for possible child abuse given social concerns.
E. Consult endocrine for congenital adrenal hyperplasia vs. diabetes mellitus.