CLIPP 16 Flashcards
what to assess first in ED pt
CAB
glasgow categories
best eye opening response, best motor response, best verbal response
glascow scores per category, and cutoffs
Eye Opening Response
4 - Eyes open spontaneously
3 - Eyes open to verbal command
2 - Eyes open to pain
1 - No eye opening
Verbal Response (see adjusted verbal response scores below for children under 5 years)
5 - Oriented
4 - Confused, but able to answer questions
3 - Inappropriate words
2 - Incomprehensible sounds
1 - No verbal response
Motor Response
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
range is 3-15, 8 or less may require urgent recusitoatn/intervnetion
adjusted _ criteria for kids under 5 with glascow
Verbal Response
5 - Smiles, orientated to sounds, follows objects, interacts.
4 - Cries but consolable, inappropriate interactions.
3 - Inconsistently inconsolable, moaning.
2 - Inconsolable, agitated.
1 - No verbal response.
why are kids more prone to dehydration
more surface area, more higher BMR (which generates and expends heat)
what is one type of OD that presents w/ tachypnea
aspirin OD
explain the vomiting in DKA
Vomiting–usually precipitated by the acidosis–is often a presenting symptom of DKA, as are increased respiratory rate and vague abdominal pain.
fever in DKA?
typically not unless confection happens to occru
what kind of abd pain in dka and why
due to acidosis it is vague and hard to localze
what is one ingestion presenting w/ abd pain
iron
possibility of - should be investigated in any child presenting with abdominal pain
pna (can be caused by inflammation of the pleura).
fluid resuscitation should begin quickly
IV fluid bolus of isotonic (0.9%, aka normal, saline) (F) at 20 mL/kg over 60 minutes
Hypotonic fluids (such as 0.45% saline) (E) and solutions with dextrose (D) are used for - fluids and are not appropriate as bolus fluids when managing -.
maintenance
hypovol
4 ways to dx dm
A patient may be diagnosed with diabetes if he/she has symptoms of diabetes (polyuria, polydipsia, and unexplained weight loss) plus a random (any time of day, without regard to time since last meal) plasma glucose concentration > 200 mg/dL (11.1 mmol/L).
A patient can also be diagnosed with diabetes mellitus with a fasting (no caloric intake for at least 8 hours) blood glucose > 126 mg/dL (7.0 mmol/L).
A patient can also be diagnosed with diabetes mellitus with a 2-hour postload glucose of > 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test.
Finally, in 2010 the ADA also voiced a position statement advocating for the use of hemoglobin A1c (HbA1c) values in the diagnosis of diabetes. A HbA1c ≥ 6.5% in an adult is diagnostic of diabetes. The test should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program (NGSP)-certified and standardized to the Diabetes Control and Complications Trial (DCCT) assay. (Many assays in common clinical use do not meet these criteria.)
vomiting, tachypnea, mental status changes, dehydration
presemtign sx of dka
dx criteria dka
A random blood glucose of > 200 mg/dL (> 11.1 mmol/L)
A venous pH < 7.3 or serum bicarbonate < 15 mEq/L (< 15 mmol/L), and
Moderate or large ketonuria or ketonemia.
tx dka
fluid bolus of 20ml/kg , insulin drip 0.1units/kg/hr typically after pt has received initial fluid expansion - typically at the same time as maintenance + replacement fluids
why shouldn’t bicarb be given in DKA
can cause cerebral edema and hypokalmia and paradoxical cns acidosis
most common diabetes associated deaht in kids
cerebral edema
when to do insulin bolus or replacem K
dont do bolus of insulin in kids. replace k only after knowing serum k.
kussmaul repirations
seen in dka, is a type of tachypnea that is deep and rapid in effort to blow off co2 and is unique bc this tachypnea is DEEP and rapid not shallow like most tachypneas.
geenral pathophysio of DKA
Type 1 diabetes is caused by a relative or absolute deficiency of insulin. Insulin facilitates the entry of glucose into peripheral tissues, and inhibits lipolysis, glycogenolysis, and tissue catabolism.
The lack of insulin and excess counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone) causes a catabolic state characterized by increased gluconeogenesis, lipolysis, and glycogenolysis, and an inhibition of glycolysis, which result in hyperglycemia and ketogenesis.
The increased lipolysis leads to increased mobilization of free fatty acids, which are then converted into ketones (acetoacetic and beta-hydroxybutyric acids).
The increased production of ketones lowers the blood pH, and leads to metabolic acidosis, which is worsened by lactic acidosis from dehydration and poor tissue perfusion.
when does osmotic diuriess in DKA happen
When circulating blood glucose levels reach ~180 mg/dL, an osmotic diuresis occurs, leading to hypovolemia, dehydration, and a loss of sodium, potassium, and phosphate in the urine.
how does hyponatremia in dka happen
hyponatremia results from the osmotic movement of water into the extracellular space in response to the hyperglycemia and hyperosmolarity (dilutional hyponatremia), as well as from increased renal sodium losses
Creatinine in DKA
high due to pre renal azotemia/dehydration, even if enal fxn ins normal
calculating corrected sodium for glucose
difference between your glucose and 100, and then divide by 100 and x 1.6. add this to sodium to get corrected.
how to replace potassium in DKA
give as KP, so this replaces both K and P. doesn’t add more cl, too!. as insulin works, the amount of K in serum drops.this reflects the true body levels of K which are down in real life due to urinary losses
the 3 types of dehydration, how they commonly occur and tx
isotonic isonatremic - water and sodium losses are equal as in gastroenteritis, diarrhea. replace over 12h (na 130-150)
hypotonic hyponatremic - when sodium loss exceeds water loss like in drinking a lot of dilate liquid or adrenal insuff. replace over 24h. na CPM
hypertonic hypernatrmeic - when water loss exceeds sodium loss like in DI, breastfeeding failure, or boiled milk. replace over 48h. na >150. correct too fast –> cerebral edema. in dka the osmotic diruesis results in hyperosmolality thus DKA pt typically get 48h fluid replacement.
how to correct dehydration with fluids in hypo and hyper natremic dehydration
hypo - calculate sodium deficit
hyper - clcaluate free water loss
replace w/ .3%, .45% or .9% depending on the dehydr level
normal urine output (approximately - for children < 15 kg and- for children > 15 kg and adults
2.0 mL/kg/hr, 1.0 mL/kg/hr
typical maint. fluid
0.25% saline (1/4 normal saline) or 0.45% saline (1/2 normal saline) with 5-10% dextrose is used to provide maintenance fluids
1gram water =
1kg water =
1ml water
1L wwater
caluclating fluid replacement if, for example, 10% dehy
pre illness weight = current weight/[ (100-%dehyd)x0.01]
then do that - illness weight to get the delta.
holliday segar vs 421
421 is per hour and HS is per 24h
100 mL/kg/day for the first 10 kg of body weight
50 mL/kg/day for the second 10 kg of body weight
20 mL/kg/day for each additional 1 kg of body weight
3 bag approach to DKA
IV insulin
A dextrose-free IV fluid containing a slightly more isotonic solution (0.675% saline) than is considered the norm, with appropriate amounts of potassium and phosphorus, and
A third fluid identical to the second except that it contains 10% dextrose as well.
The rate of infusion of the dextrose-free fluid and the dextrose-containing fluid are tapered up and down as needed to meet glucose targets, while insulin is delivered at a constant rate of 0.1 units/kg/hour.
risk factors for, and signs of, cerebral edema in terms of BP, HR, BUN, level of acidosis, serum sodium and giving or not giving bicarb
high bp, low hr, tachypnea, third n palsy, vomiy, high bBUN, high acidosis, rise in sodium, giving bicardb
what kind of testing is required annually for T1 DM kids
thyroid fxn test but only after presenting metabolic derangements are corrected
multi factorial
environmental and genetic factors
hoenymoon phase
“Honeymoon Phase”
Within one month of diagnosis, most pediatric patients with type 1 diabetes go through a honeymoon phase in which they have a temporary remission of diabetes. Patients require little exogenous insulin during the honeymoon phase. Parents, understandably, may assume that their child has been “cured.” This phenomenon should be discussed at the time of the original diagnosis.
Children recovering from DKA may require up to 1 unit/kg per day of insulin.
Children without DKA at presentation may be treated with 0.25 to 0.75 unit/kg per day, depending on age and pubertal status.
.1
.25-.75
ADA recommendations for screening high risk [ppl wfor dm2
bmi >85%< weight for height >85th, erojhy >120 of ideal.
plus any of following 2:Maternal history of diabetes or gestational diabetes during the child’s gestation.
Family history of type 2 diabetes in a first- or second-degree relative
Race/ethnicity (Native American, African American, Latino, or Asian American, Pacific Islander)
Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome).
at 10 yrs or puberty onset and 3 years after that
cushing triad
hypertension ,bradycardia, irregular (c-s) breathing
high icp sx
c-s breathing, bradycardia, epigastric discomfort due to vagal smimulation
