CLIPP 16

Question 1

what to assess first in ED pt

Answer 1

CAB

Question 2

glasgow categories

Answer 2

best eye opening response, best motor response, best verbal response

Question 3

glascow scores per category, and cutoffs

Answer 3

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

Question 4

adjusted _ criteria for kids under 5 with glascow

Answer 4

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.

Question 5

why are kids more prone to dehydration

Answer 5

more surface area, more higher BMR (which generates and expends heat)

Question 6

what is one type of OD that presents w/ tachypnea

Answer 6

aspirin OD

Question 7

explain the vomiting in DKA

Answer 7

Vomiting–usually precipitated by the acidosis–is often a presenting symptom of DKA, as are increased respiratory rate and vague abdominal pain.

Question 8

fever in DKA?

Answer 8

typically not unless confection happens to occru

Question 9

what kind of abd pain in dka and why

Answer 9

due to acidosis it is vague and hard to localze

Question 10

what is one ingestion presenting w/ abd pain

Answer 10

iron

Question 11

possibility of - should be investigated in any child presenting with abdominal pain

Answer 11

pna (can be caused by inflammation of the pleura).

Question 12

fluid resuscitation should begin quickly

Answer 12

IV fluid bolus of isotonic (0.9%, aka normal, saline) (F) at 20 mL/kg over 60 minutes

Question 13

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 -.

Answer 13

maintenance

hypovol

Question 14

4 ways to dx dm

Answer 14

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.)

Question 15

vomiting, tachypnea, mental status changes, dehydration

Answer 15

presemtign sx of dka

Question 16

dx criteria dka

Answer 16

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.

Question 17

tx dka

Answer 17

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

Question 18

why shouldn’t bicarb be given in DKA

Answer 18

can cause cerebral edema and hypokalmia and paradoxical cns acidosis

Question 19

most common diabetes associated deaht in kids

Answer 19

cerebral edema

Question 20

when to do insulin bolus or replacem K

Answer 20

dont do bolus of insulin in kids. replace k only after knowing serum k.

Question 21

kussmaul repirations

Answer 21

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.

Question 22

geenral pathophysio of DKA

Answer 22

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.

Question 23

when does osmotic diuriess in DKA happen

Answer 23

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.

Question 24

how does hyponatremia in dka happen

Answer 24

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

Question 25

Creatinine in DKA

Answer 25

high due to pre renal azotemia/dehydration, even if enal fxn ins normal

Question 26

calculating corrected sodium for glucose

Answer 26

difference between your glucose and 100, and then divide by 100 and x 1.6. add this to sodium to get corrected.

Question 27

how to replace potassium in DKA

Answer 27

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

Question 28

the 3 types of dehydration, how they commonly occur and tx

Answer 28

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.

Question 29

how to correct dehydration with fluids in hypo and hyper natremic dehydration

Answer 29

hypo - calculate sodium deficit
hyper - clcaluate free water loss
replace w/ .3%, .45% or .9% depending on the dehydr level

Question 30

normal urine output (approximately - for children < 15 kg and- for children > 15 kg and adults

Answer 30

2.0 mL/kg/hr, 1.0 mL/kg/hr

Question 31

typical maint. fluid

Answer 31

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

Question 32

1gram water =

1kg water =

Answer 32

1ml water

1L wwater

Question 33

caluclating fluid replacement if, for example, 10% dehy

Answer 33

pre illness weight = current weight/[ (100-%dehyd)x0.01]

then do that - illness weight to get the delta.

Question 34

holliday segar vs 421

Answer 34

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

Question 35

3 bag approach to DKA

Answer 35

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.

Question 36

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

Answer 36

high bp, low hr, tachypnea, third n palsy, vomiy, high bBUN, high acidosis, rise in sodium, giving bicardb

Question 37

what kind of testing is required annually for T1 DM kids

Answer 37

thyroid fxn test but only after presenting metabolic derangements are corrected

Question 38

multi factorial

Answer 38

environmental and genetic factors

Question 39

hoenymoon phase

Answer 39

“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.

Question 40

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.

Answer 40

.1

.25-.75

Question 41

ADA recommendations for screening high risk [ppl wfor dm2

Answer 41

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

Question 42

cushing triad

Answer 42

hypertension ,bradycardia, irregular (c-s) breathing

Question 43

high icp sx

Answer 43

c-s breathing, bradycardia, epigastric discomfort due to vagal smimulation