Case 16 Flashcards
What are key findings from the history of a child with DKA?
History of vomiting, polydipsia, altered mental status, abdominal pain.
What are key findings from the physical exam of a child with DKA?
Afebrile, Dehydration (tachycardic, dry oral mucosa, sunken eyes, skin tenting), Tachypneic
What is on the differential diagnosis for DKA?
Appendicitis, Increased ICP, Toxic ingestion, DKA, GI obstruction, Gastroenteritis, Pyelonephritis, Bacterial pneumonia
What are key findings from testing with DKA?
Hyperglycemia and Metabolic acidosis.
Glasgow coma scale (GCS):
- The most commonly accepted method for assessing patients with an altered level of consciousness
- The scale is used to assign a score in three categories (Best Eye Response, Best Verbal Response, and Best Motor Response)
- The three scores are added to result in a total score, with the highest possible score of 15.
- Patients with GCS of less than or equal to 8 may require aggressive intervention and management.
What is the eye-opening response scale of the GCS?
6 - N/A 5 - N/A 4 - Eyes open spontaneously 3 - Eyes open to verbal command 2 - Eyes open to pain 1 - No eye opening
What is the Verbal response scale of the GCS?
6 - N/A 5 - Oriented 4 - Confused, but able to answer questions 3 - Inappropriate words 2 - Incomprehensible sounds 1 - No verbal response
What is the Motor response scale or the GCS?
6 - Obeys commands
5 - Localizes pain
4 - Withdraws from pain
3 - Abnormal flexion, decorticate posture
2 - Extensor response, decerebrate posture
1 - No motor response, flaccid
What is the adjusted verbal response criteria for children under the age of five years?
5 - Smiles, oriented to sounds, follows objects, interacts
4 - Cries but consolable; inappropriate interactions
3 - Inconsistently inconsolable, moaning
2 - Inconsolable, agitated
1 - No verbal response
Type 1 diabetes:
Formerly called juvenile-onset or insulin dependent diabetes (IDDM).
Epidemiology of Type 1 diabetes:
Accounts for 5-10 percent of all people with diabetes.
What is the etiology of type 1 DM?
Either complete lack of, or too little, insulin. Thought to be caused by immune system-induced destruction of beta cells of the pancreas.
What is the presentation of type 1 DM?
Symptoms usually start in childhood or young adulthood. At presentation, patients are often seriously ill from sudden symptoms of high blood sugar at presentation.
What is the epidemiology of Type 2 DM?
Incidence of type 2 diabetes has recently increased (up to 10 fold) among pediatric population and accounts for up to half of all new cases of diabetes in certain populations.
What is the etiology of type 2 DM?
Inability of the body tissues to respond properly to insulin. Risk of resistance associated with genetics, obesity, increasing age, and duration of hyperglycemia.
What are risk factors for type 2 DM?
- Obesity: Mean body mass index (BMI) among children with type 2 DM is greater than 95th reference percentile for age
- Ethnicity: More prevalent in Native American, African American, Latino, Asian American, Pacific Islander populations.
- Age: peak age at diagnosis in youth is between 12 and 16 years (midpuberty)
- Sex (female, 3:1)
- Sedentary lifestyle
How does type 2 DM present?
May not have symptoms before diagnosis. Usually diagnosed in adulthood.
What screening is recommended for Type 2 DM?
ADA recommends checking fasting plasma glucose level every three years beginning at age 10 years (or onset of puberty if this is earlier) when:
- Child is overweight (BMI greater than 85th percentile for age and sex, weight for height greater than 85th percentile, or weight greater than 120 percent of ideal for height); plus has…
- Any two of the following risk factors:
- -Maternal history of diabetes or gestational diabetes during the child’s gestation
- -Family history of type 2 DM in a first or second degree relative
- -Race/ethnicity (Native American, AA, Latino, or Asian American, Pacific Islander)
- -Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, HTN, dyslipidemia, polycystic ovary syndrome)
What are four ways to diagnose diabetes according to the American Diabetes Association (ADA)?
- Sx of diabetes (polyuria, polydipsia, and unexplained weight loss) plus random (any time of day without regard to time since last meal) plasma glucose concentration greater than or equal to 200 mg/dL (11.1 mmol/L)
- Fasting (no caloric intake for at least 8 hours) blood glucose greater than or equal to 126 mg/dL (7.0 mmol/L)
- Two-hour post-load glucose greater than or equal to 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test
- Hemoglobin A1c (HbA1c) value greater than 6.5 percent in specifically certified laboratories
In the absence of unequivocal hyperglycemia or sx, results should be confirmed by repeating on a different day.
Diabetic ketoacidosis (DKA):
- A condition caused by relative or absolute deficit of insulin. Usually occurs in patients with type 1 diabetes, but can occasionally be found in patients with type 2 diabetes.
- Freq. of DKA at onset of diabetes inversely correlates with the regional incidence of type 1 diabetes in Europe and North America.
- Lack of insulin and excess glucagon and other coutnerregulatory hormones leads to a catabolic state resulting in hyperglycemia, excess ketones, and acidosis
- Increased lipolysis leads to increased mobilization of free fatty acids, which are then converted into ketones (acetoacetic and beta-hydroxybutyric acid); increased ketones lowers blood pH and leads to metabolic acidosis.
- When blood glucose levels reach about 180 mg/dL, osmotic diuresis occurs, leading to hypovolemia, dehydration, and a loss of sodium, potassium, and phosphate in the urine. Osmotic diuresis and hyperglycemia cause serum hyperosmolarity.
What is the diagnosis criteria for DKA?
- Random blood glucose greater than 200 mg/dL (greater than 11.1 mml/L)
- Venous pH less than 7.3 or serum bicarbonate less than 15 mEq/L (less than 15 mmol/L)
- Moderate or large ketonuria or ketonemia
What are there three main types of dehydration?
- Isotonic/isonatremic
- Hypotonic/hyponatremic
- Hypertonic/hypernatremic
Isotonic/Isonatremic:
(Sodium = 130-150 mEq/L or mmol/L) Sodium and water losses are balanced. This is the most common type of dehydration in children, including children presenting with acute gastroenteritis.
Hypotonic/hyponatremic:
(sodium less than 130 mEq/L or mmol/L) Sodium losses exceed water losses. Mild forms can be seen in viral gastroenteritis. More severe forms (less than 120 mEq/L) can be seen in free water or diluted formula replacement, or in adrenal insufficiency.
Hypertonic/hypernatremic:
(sodium greater than 150 mEq/L or mmol/L) Water losses exceed sodium losses. This is seen most commonly in breastfeeding failure, use of inappropriate rehydration solutions, and diabetes insidious. Associated with highest mortality.
Using foreign language interpreters:
Failure to appreciate the important of culture and language in pediatric emergencies may result in multiple adverse consequences, including:
- Difficulties obtaining informed consent
- Miscommunication
- Dissatisfaction with care
- Lower quality of care
- Physician bias
Why do children have a higher risk of dehydration than adults?
- Higher surface area-to-body mass ratio
- Higher basal metabolic rate
- Higher percent body water
What does the physical exam look like in MILD dehydration?
Neurological status - alert, consolable or irritable. Pulse - age-appropriate or slightly increased. Buccal mucosa/lips - Moist or tacky. Eyes - Moist, not sunken. Tears, if crying - present. Urine output - Diminished. Fontanel (if patent) - flat. Skin (touch) - Unremarkable. Skin (turgor) - good. Capillary refill - less than 2 seconds.