4 endo/metabolic/nutrition

Question 1

You consider/diagnose CAH in neonate

-what immediate tx, things to do?

Answer 1

• treat electrolyte abnormalities–glucose, hyperK
• give hydrocort 25mg (50mg for larger children)
• draw extra RED TOP before giving meds, for inpatient team labs

Question 2

In ml/kg, how much dehydration in a kid? and what sxs/signs for each?

mild, mod, severe

Answer 2

mild: 50 – dry mucus membranes
mod: 100 – cap refill >2 sec, tachy, decreased UOP
severe: 150 – ANS, sunken fontanelle, skin turgor, hypotensive

Question 3

zofran for peds:

• what dose?
• should you use other antiemetics?

Answer 3

general guideline:

2mg for small 8-15kg, 4mg for med 15-30kg, 8mg for larger

don’t use other antiemetics under age 5. if zofran doesn’t work think worse things

Question 4

HypoNA

-tx

Answer 4

if sxs: 10ml/kg 3% hypertonic saline over 1 hour

if not sxs, admit for appropriate fluids

Question 5

hypocalcemia

-dose of ca gluconate in symptomatic

Answer 5

0.5 - 2 cc/kg slow IV

lethargy, seizures, etc

Question 6

Peds DKA
-how to start fluid management

Answer 6

In general:

start 10-20 ml/kg bolus NS over 1st 2 hours. (that’s it, GENTLE)

then NS 1.5-2x maintenance 4-6h

Question 7

Peds DKA

• insulin dose
• what if you want subQ insulin

Answer 7

start 0.1 mg/kg gtt no bolus, after checking K

if pt looks well: subQ is 0.3U/kg

Question 8

Peds DKA:
how much K to give to start?

Answer 8

If K wnl, then give 40 mmol/L repletion along with fluids, insulin

(mmol/L)

Question 9

Peds DKA: You suspect cerebral edema

• do what things?
• not getting better, what to do for intubation?

Answer 9

1. check glucose!
2. tx: mannitol 0.5-1 g/kg over 20 min, give repeat dose if no response (Same as adult dosing)

or 3% hypertonic saline 5-10 ml/kg over 30min (adult dosing is 250cc 3% bolus). Initial dose can go through peripheral line.

• HOB up
• careful fluids! restrict fluids but also know mannitol will diurese and you need to replete
  3. CT head
  4. call NSG, PICU

Intubate: ICP protective intubation. consider lidocaine 1% 1 ml/kg bolus, fentanyl as well

Question 10

Cerebral edema

you gave mannitol 1 dose. When to try 2nd dose?

Answer 10

should see effect in 30 min

do repeat dose if no change. 0.5-1 g/kg bolus over 20min

Question 11

Hypertonic saline: doses (adult and peds) for:

• symptomatic hyponatremia
• elevated ICP

Answer 11

Remember: 3%, 8.4% 50mL in crashcart (osmolarity is actually equivalent to 6% saline, and 1 amp is 50ml), 23.4%

Symptomatic hypoNa:

Adult dose: 100 cc 3% over 10min, can repeat once. Can do 50 ml 8.4% NaHCO3 from crash cart, then repeat. can be in good PIV. Each 100 ml raises ~2mmol Na

Peds: 2 ml/kg 3% over 10-60min

Elevated ICP:

Adult: 250-500ml 3%, can give 2 amps of NaHCO3 8.4%, 30-60ml 23.4%

Peds: 3% 3-10ml/kg over 10-60 min

Adult dosing for both: Can start 2 amps NaHCO3 from crash cart

Peds: ?

Question 12

IEM inborn errors metabolism

• 2 classic presentations to remember
• Additional labs to get if you suspect (4 things)
• hypoglycemia tx
• how to fluid resus

Answer 12

1. crashing neonate on week 1
2. 1 month infant. lethargic/vomit/seizures. Normal labs
   - VBG (looking for acidosis), lactate, NH3, ketones (urine)
   - D10 5-10 ml/kg

IVF: 10 ml/kg boluses, then maintenance D10 1/4NS @ 1.5-2x maintenance