Vomiting and DKA Flashcards
Increased risk of dehydration in children
- Have higher risk because greater surface area to body mass ratio –> more evaporation
- high BMR –> more energy and expend water
- high % of weight is water
Diagnosing diabetes
- having symptoms of diabetes and random glucose >200
- fasting glucose >126
- 2-hour post load of >200
- HbA1c > 6.5%
- may need to repeat test
Diagnosing DKA
Sx = vomiting, tachypnea, altered mental, dehydration
- random glucose >200
- venous pH
DKA epidemiology
usually in type 1 diabetics
- wide variation
Presentation of DKA
vomiting, weight loss, dehydration, SOB, abdominal pain, change in level of consciousness
Pathophysiology of DKA
- relative or absolute deficiency in insulin (facilitates entry of glucose into peripheral tissues)
- lack of insulin causes catabolic state of increased gluconeogenesis and lipolysis and glycogenolysis
- increased lipolysis leads to increased FFA –> ketones
- increased ketones –> lower blood pH –> acidosis
- osmotic diuresis –> hypovolemia, dehydration, loss of electrolytes
- intravascular volume depletion –> catecholamines –> lipolysis –> bad cycle
Labs in DKA
Hyponatremia - osmotic movement of water in response to hyperglycemia, renal sodium loss
Potassium - appears normal becuase of low insulin but is actually depleted, needs to be replaced during treatment
Bicarb - low because of acidosis
Creatinine - normal or elevated
Glucose - high
Ketones - high
Types of dehydration
Isotonic - normal sodium levels because sodium and water lost from vomiting or diarrhea (tx over 12 hrs)
Hypotonic - sodium lost exceeds water lost (dilute fluids consumed in dehydration) tx = 24 hrs
- central pontine myelinolysis can occur
Hypertonic - water lost exceeds sodium lost (diabetes insipidus) tx = 48 hrs
- cerebral edema if corrected too fast
Type 2 diabetes
usually normal or high levels of insulin but insulin resistance occurs (unable to respond)
Risk factors: obesity, ethnicity, age, female, sedentary
GCS eyes
4 - open spontaneously
3 - open on command
2 - open to pain
1 - none
GCS verbal
5 - oriented 4 - confused but answers questions 3 - inappropriate words 2 - incomprehensible 1 - none
GCS motor
6 - obeys commands 5 - localizes pain 4 - withdraws from pain 3 - abnormal flexion (decorticate) 2 - abnormal extension (decerebrate) 1 - none (flaccid)
DDx of vomiting and altered mental status
DKA toxins GI obstruction ICP Gastroenteritis Appendicitis Bacterial PNA Pyelonephritis
DKA
vomiting usually precipitated by acidosis, increased RR and abdominal pain
- polyuria and polydipsia, diffuse abdominal pain
- dehydration, altered mental status
- tacypnea (Kussmaul respirations)
Toxic ingestion
vomiting, altered mental status and obtundation
- dehydration possible
aspirin overdose causes tacypnea
GI obstruction
vomiting from obstruction
almost all dehydrated from vomiting
abdominal pain
ICP
can present as vomiting
Gastroenteritis
most common cause of vomiting
fever, colicky ab pain, and diarrhea
Appendicitis
RLQ ab pain with possible vomiting
Bacterial PNA
should be investigated because inflammation of pleura can present as ab pain
- septic patients can present with altered mental status and dehydration is also possible
Pyelonephritis
vomiting may be seen that leads to dehydration
- distinguish frequency from polyuria
Further studies with newly diagnosed diabetes
autoimmune thyroid disease and celiac disease
Prioritize managing DKA
- ABCs
- Fluid bolus (20 mL/kg)
- Blood glucose, CV monitor, UA, blood gas and electrolytes
- Insulin administration (0.1 units/kg/hr)
- Add potassium later
- Admit to hospital
- consult endo
Admission orders for DKA
Continous CV monitor, hourly neuro checks, monitor I/O Insulin order Check glu every 1 hr Check Ca, Mg, and P on admission Check pH every 1 hr Dipstick urine
