Peds Sessions Flashcards
how do you manage DKA in office vs. ER?
outpatient: can do glucometer, urinalysis (will show positive glucose, ketones and glucose amount)
Emergency Department:
- Give IV fluids (Hurry up and slow down - if kid is in shock, need to make sure to act fast, but then back off otherwise could cause cerebral edema)
- Obtain labs
What are electrolyte disturbances in DKA?
- potassium levels: lack of insulin decreases potassium in cells –> goes into blood –> lost in urine –> hypokalemia (problems in heart rate)
- bicarbonate levels decrease d/t to system being overwhelmed (not recommended to replace)
Definition of anion gap acidosis
= ([Na+] + [K+]) − ([Cl−] + [HCO3−])
normally gap is under 10!!!
Complications of DKA
- Mortality: 0.15-0.5%, most often due to cerebral edema. Higher risk in younger children, initial event and severity of acidosis. Usually occurs in first 12 hrs of treatment
- Cardiac arrhythmias
- Venous thrombosis
- Aspiration
- Cognitive impairment
Sx of DKA?
Vomiting (coffee ground), dehydration, deep gasping breathing, confusion and occasionally coma,
** need to have high blood sugar levels to ddx **
how do you rehydrate pt. w/ DKA?
- give IV bolus 10-20 ml/kilo to stabilize CV status
- provide maintentance fluids (4ml/hour first 10kg, 2 ml/hour second 10 kg, 1 kilo/hour for next)
- add K+ as Kacetate and KCl, as well as sodium (failure of sodium to improve may indicate cerebral edema)
- add insulin 0.5-0.1 unit/kg/hr (also helps to drive K+ intracellularly)
- also promotes metabolism of ketoacids producing HCO3, stops new ketoacid production
** fluids improve renal fn –> enhanced excretion of ketone bodies and improved tissue perfusion to decrease lactic acidosis
monitor labs!
when do you stop fluids for DKA?
1) Anion gap less than 12
2) Venous pH greater than 7.3 or HCO3 greater than 15
3) Glucose less than 200
4) Tolerating oral intake
anion gap acidosis causes?
MUDPILES
methanol, uremia, diabetic ketoacidosis, propylene glycol, isoniazid, lactic acidosis, ethylene glycol, salicylates
EKG reading with DKA?
hypoK: flat T waves, U wave, prolonged PR interval
HyperK: peaked T waves
why do you not give bicarb w/ DKA?
- Paradoxical rise in CNS pH due to decreased resp rate
- Slows recovery of ketosis
- Post treatment alkalosis
- Risk of increasing hypokalemia
- May increase osmolality prior to decrease in glucose
- Increased risk of cerebral edema
presentation of thyroid cancer in adolescents
- seen as a result of radiation to neck/face/brain
- most often papillary/follicular carcinomas or mixed
- MENII syndrome also seen
- mets often present in anterior cervical nodes
management of thyroid cancer in adolescents
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ddx for localized lymphadenopathy in YA’s
Oropharyngeal infection (viral, group A streptococcal, staphylococcal)
Scalp infection
Mycobacterial lymphadenitis (tuberculosis and nontuberculous mycobacteria)
Viral infection (EBV, CMV, HHV-6)
Cat scratch disease
Toxoplasmosis
Kawasaki disease- strawberry tongue, fever for 5+ days, swollen cervical lymph nodes, blood shot eyes, rash
Thyroid disease
Kikuchi disease- swollen gland w/ fever in young teenage women
Sinus histiocytosis
Autoimmune lymphoproliferative disease
Lymphoma, Hodgkins and nonHodgkins
presentation/management of thyrotoxicosis in YA’s
- Graves, Hashitoxicosis, pituitary tumor, TMNG, postpartum thyroiditis
- usually see family hx of thyroid disease
sx: nervousness, disturbed sleep, w/l or w/g, tremor, sweating, heat intolerance, mm. weakness, fatigue, increased heigh, delayed sexual maturation, menstrual abnormalities
- tachycardia, palpitations
tx: antithyroid drug (firstline)
- radioactive iodine (second, proven safe for use in children)
- subtotal thyroidectomy (not often used d/t complications)
presentation/management of prolactinoma in YA’s
- Girls: present w/ delayed puberty, amenorrhea, galactorrhea
boys: present w/ delayed puberty, gynecomastia, galactorheaa - decreased energy, decreased libido, impotence, growth failure
** may also be caused by pregnancy, meds, renal/hepatic disease, or marijuana!
The diagnosis of prolactinoma requires laboratory results of sustained hyperprolactinemia and imaging evidence of pituitary adenoma
Prolactin levels can be falsely elevated in the presence of macroprolactin, a complex of prolactin and an IgG antibody that has a reduced rate of clearance and reduced bioactivity. The presence of macroprolactin should be confirmed by polyethylene glycol precipitation, particularly in a patient with a moderately elevated prolactin level and less typical symptoms
tx: primary therapy is medical - dopamine receptor agonists (cabergoline)