Minty Fresh and Unconscious

Scene

At 0800 on a beautiful Saturday morning, Attack One responds to a report of an unconscious child. The crew is told en route that the mother found her daughter unresponsive but breathing. The hysterical mother greets the crew at the door and takes them quickly to the master bedroom upstairs. The three-year-old child is on the bed. She is unresponsive to verbal stimuli, but withdraws from painful stimuli. She is breathing normally, has no signs of trauma and has no underlying medical problems. Her skin is warm and dry.

Taking care to maintain a calm demeanor, the crew reassures the mother and begins looking for clues. Mom was downstairs cleaning house for the past hour, Dad has been at work since early morning, and there are no other children in the house. Only a few over-the-counter medicines are found in the house. Mom thought the child was watching cartoons in the parents’ bed while Mom cleaned. The child had not eaten since dinner the evening before. Mom heard no falls or other unusual activity, and the child has no signs of an injury.

“Let’s take a look at the medicines,” suggests one paramedic. These are all in the master bathroom. One crew member accompanies Mom into that room, and as they enter, Mom notes that the mouthwash bottle is out of place on the counter. The top is on, and the bottle is about half full. The paramedic immediately raises the potential that the child drank from the bottle.

The medic asks his partner to check the child’s blood sugar and asks Mom to get all the medicine bottles out. She digs through the cabinets, finding nothing out of place—the bottles of OTC pain medicines and decongestants are mostly full.

The child’s blood sugar is 23. An intravenous line is started without resistance from the child, a bolus of dextrose is administered, and the child wakes up quickly. “I’m hungry!” she says.

These words bring comfort to mother and crew alike. The crew members carefully smell the breath of the child and find the faint odor of the mouthwash. The child can’t remember drinking the liquid, but the bottle is clearly out of place, according to the mother.

The crew then educates the mother. Even small amounts of alcohol—like those in mouthwash and things like leftover drinks and cold preparations—can dramatically reduce a child’s blood sugar. This child needs to eat something to maintain her blood sugar and prevent a relapse. She needs to go to the hospital to ensure that nothing else caused the episode of hypoglycemia. The child is not nauseated, so she drinks some juice and eats some crackers. Transport to the hospital is uneventful.

Hospital Course

By the time she arrives in the ED, the patient is playful and happy. Her blood sugar is now 92. She eats a full breakfast and, with no other abnormalities found, returns home after a four-hour period of observation.

Case Discussion

Ethanol is a well-known sedative-hypnotic. It induces hypoglycemia in infants due to their limited stores of glycogen. Children who don’t have a steady supply of glucose in their diets are profoundly affected by alcohol, and may develop hypoglycemia with very small volumes of ethanol intake. Such small amounts of alcohol can be contained in things like mouthwash, vanilla extracts, perfumes and certain cough and cold preparations. The mechanism is complex and relates to the basic processes the body uses to synthesize sugars and fatty acids. Some metabolites of alcohol may be involved in directly reducing blood sugar. The mechanism of producing hypoglycemia is the same in the very malnourished chronic-alcoholic adult, and in these individuals, profound hypoglycemia can occur. In many communities, thiamine (a complex B vitamin) is given to the hypoglycemic alcoholic patient before the dextrose solution is administered, to allow appropriate metabolism of the glucose in the brain. In hypoglycemic children, thiamine is not needed. The lack of glycogen stores also means that glucagon would have limited utility in reversing hypoglycemia in infants and chronic-alcoholic patients.

Children and severe alcoholics also lack the profound diaphoresis that occurs in most adult episodes of hypoglycemia. This child was not diaphoretic.

Mouthwash ingredients can vary, but several brands contain large amounts (26%–28%) of ethanol. A few also contain salicylates, fluoride and/or essential oils, but in very small amounts, so the concern with pediatric mouthwash ingestions is usually limited to ethanol.

An important message in community education is the strict avoidance of alcohol exposure in small children. Even the small amount of alcohol in an unfinished cocktail left over from a party the night before can produce marked hypoglycemia in a child.

In looking for causes of altered levels of consciousness in children, remember the causes you find in adult encounters. Fingerstick blood sugars can reveal a rapidly reversible cause of the mental status lapse.