Peds 16 Flashcards
Isabella is a 7-year-old female with vomiting, diffuse abdominal pain, and dehydration who also has polydipsia and enuresis. On exam she is lethargic, tachypneic, and tachycardic, but normotensive and without peritoneal signs.
What’s the leading diagnosis? What labs would you order?
DKA
fingerstick CBG, BMP/CMP, venous blood gas, UA
Hx: Type 1 DM
S/s: headache, recurrent vomiting, restlessness/irritability, and lethargy.
On exam: cranial nerve palsies and abnormal pupillary response
What complication are you most concerned for?
Cerebral edema
What is Cushing’s triad and what does it indicate?
- Inappropriate slowing of heart rate (bradycardia)
- rising blood pressure (widened pulse pressure)
- irregular respirations
Indicates increased intracranial pressure (ICP)
What is Kussmaul respirations and what does it indicates?
Pattern of rapid and deep breathing. Indicative or DKA as patient is trying to blow off excess CO2 caused by metabolic acidosis
What are the initial management steps for DKA?
- IV bolus NS → mIVF
- Insulin drip 0.1 units/kg/hr
- Monitor CBG every 30 min to 1 hour
- Consult endocrinologist
- Admit inpatient PICU
What are the expected blood gas lab abnormalities in DKA?
Metabolic acidosis
pH < 7.3, bicarb <18, anion gap > 12
What is the diagnostic criteria for DKA?
- random blood glucose of > 250
- pH < 7.3
- bicarbonate < 18 mEq/L
- presence of ketones in blood or urine
A 15-year-old female is brought to the ER with a chief concern of abdominal pain for three hours. She rates her pain at 8/10 and describes it as constant and located mainly in the middle of her abdomen. It is worse with coughing and moving. She had two episodes of nonbilious, non-bloody vomiting. She is sexually active with her boyfriend of three months and always uses condoms. Her last menstrual period was two weeks ago. Vital signs are normal. On exam, she exhibits involuntary guarding, mild rebound tenderness, and tenderness to palpation between her right anterior superior iliac spine and umbilicus. On pelvic exam, she reports tenderness when attempting to palpate her right adnexa, but no masses are appreciated and there is no cervical motion tenderness. Laboratory studies reveal normal complete blood count and c reactive protein. Which of the following is the most likely diagnosis in this patient?
A. Appendicitis
B. Ectopic pregnancy
C. Ovarian torsion
D. Pelvic inflammatory disease
A. Appendicitis
A 4-year-old female with a history of type 1 diabetes mellitus was admitted to a local hospital for treatment of DKA. A few hours after the treatment, she develops grunting, irregular respirations, and has vomited twice. On exam, when asked to gaze forward, her left eye is pointing downward and out. Her diastolic blood pressure is 90 mmHg. What is a likely diagnosis?
A. Cerebral edema B. Hypoglycemia C. Hypokalemia D. Hyponatremia E. Pneumonia with possible sepsis
A. Cerebral edema
A 9-year-old female is brought to clinic by her mother because of two days of abdominal pain and vomiting. She has vomited six times today and has had decreased appetite, but no diarrhea, fevers, sick contacts, or changes in her diet. Her mom states that she has been otherwise healthy apart from increased thirst and occasional bedwetting over the last few weeks. Of note, the patient’s maternal grandmother suffers from celiac disease. On exam, the patient is afebrile, has a heart rate (HR) of 180 bpm, BP 90/60 mmHg, RR 50 bpm, and O2 saturation of 98%. She is lying in bed appearing slightly drowsy, taking rapid, deep breaths, and is slow to respond to questions. Her heart and lung exams are normal apart from being tachycardic, and her abdominal exam reveals mild diffuse tenderness to palpation with no rebound or guarding. Which of the following would be the most appropriate next step in management?
A. Abdominal ultrasound B. AP and lateral chest x-ray C. Fingerstick blood glucose D. Gastric lavage E. Midstream urine culture
C. Fingerstick blood glucose
A 9-year-old male presents to the emergency department in an ambulance after he was found unconscious at a local playground. In the ED he is lethargic and difficult to arouse. He is able to minimally verbalize that his head and stomach hurt. He vomits clear liquid twice over the course of 30 minutes. Vital signs are as follows: T 37.6 C, HR 66 bpm, BP 155/80 mm Hg, RR 18 bpm. His respirations are irregular with brief episodes of apnea. On physical exam you are unable to reproduce the abdominal pain and there is no rebound tenderness or guarding. The rest of the physical exam is unremarkable. Which of the following is the most likely diagnosis?
A. Appendicitis B. Diabetic ketoacidosis C. Intracranial hemorrhage D. Small bowel obstruction E. Viral gastroenteritis
C. Intracranial hemorrhage
Increased ICP can be secondary to epidural or subdural hemorrhage. It is possible the patient may have fallen while playing in the playground. Increased ICP can present as the classic Cushing’s triad: hypertension, inappropriate slowing of the heart rate, and irregular respirations (Cheyne-Stokes respiration). Lastly, the patient’s headache and non-bilious vomiting can also be attributed to the increased ICP.
A 7-year-old male is brought by ambulance to the ED because of decreased mental status for two hours. His parents say that he has been tired for the past three days. Six hours ago, he began vomiting, but has not had diarrhea. He is difficult to arouse and moans with stimulus. Temperature is 98.6, pulse is 124 beats/minute, respirations are 28 breaths/minute, blood pressure is 96/68 and oxygen saturations are 99% on room air. Physical exam findings include dry mucous membranes and moaning on palpation of the abdomen. The remainder of the exam is normal. What is the most likely cause of his condition?
A. Appendicitis B. Diabetic ketoacidosis C. Non-accidental trauma D. Opioid overdose E. Sepsis
B. Diabetic ketoacidosis
What would you expect to see on an electrolyte panel if you suspect a child has DKA?
Na low, K normal, creatinine high
A child is approximately 10% dehydrated with a current weight of 22kg. She’s already been given 220mL in fluid boluses. Calculate the fluid rate over the next 48 hours?
Rate for fluid deficit
- 22kg now w/ 10% dehydration → 24.4kg pre-illness weight
- 24.4 - 22 = 2.4kg lost
- 2.4kg x (1L / 1kg) = 2.4 L → 2400mL os the total fluid deficit amount
- 2400mL - 220mL = 2180mL remaining deficit
- 2180mL / 48 hours = 45 mL/hr IV rate
mIVF rate (per body weight), using 4, 2, 1 mL/kg/hr - 22kg → 40 + 20 + 2 = 62 mL/kg/hr
Total IV fluid rate = 45 + 62 = 107 mL/hr
What is the calculation for anion gap?
Na - (Cl + HCO3)
