Vomiting and DKA

Question 1

Increased risk of dehydration in children

Answer 1

• 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

Question 2

Diagnosing diabetes

Answer 2

1. having symptoms of diabetes and random glucose >200
2. fasting glucose >126
3. 2-hour post load of >200
4. HbA1c > 6.5%
   - may need to repeat test

Question 3

Diagnosing DKA

Answer 3

Sx = vomiting, tachypnea, altered mental, dehydration

• random glucose >200
• venous pH

Question 4

DKA epidemiology

Answer 4

usually in type 1 diabetics

- wide variation

Question 5

Presentation of DKA

Answer 5

vomiting, weight loss, dehydration, SOB, abdominal pain, change in level of consciousness

Question 6

Pathophysiology of DKA

Answer 6

• 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

Question 7

Labs in DKA

Answer 7

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

Question 8

Types of dehydration

Answer 8

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

Question 9

Type 2 diabetes

Answer 9

usually normal or high levels of insulin but insulin resistance occurs (unable to respond)
Risk factors: obesity, ethnicity, age, female, sedentary

Question 10

GCS eyes

Answer 10

4 - open spontaneously
3 - open on command
2 - open to pain
1 - none

Question 11

GCS verbal

Answer 11

5 - oriented
4 - confused but answers questions
3 - inappropriate words
2 - incomprehensible
1 - none

Question 12

GCS motor

Answer 12

6 - obeys commands
5 - localizes pain
4 - withdraws from pain
3 - abnormal flexion (decorticate)
2 - abnormal extension (decerebrate)
1 - none (flaccid)

Question 13

DDx of vomiting and altered mental status

Answer 13

DKA
toxins
GI obstruction
ICP
Gastroenteritis
Appendicitis
Bacterial PNA
Pyelonephritis

Question 14

DKA

Answer 14

vomiting usually precipitated by acidosis, increased RR and abdominal pain

• polyuria and polydipsia, diffuse abdominal pain
• dehydration, altered mental status
• tacypnea (Kussmaul respirations)

Question 15

Toxic ingestion

Answer 15

vomiting, altered mental status and obtundation
- dehydration possible
aspirin overdose causes tacypnea

Question 16

GI obstruction

Answer 16

vomiting from obstruction
almost all dehydrated from vomiting
abdominal pain

Question 17

ICP

Answer 17

can present as vomiting

Question 18

Gastroenteritis

Answer 18

most common cause of vomiting

fever, colicky ab pain, and diarrhea

Question 19

Appendicitis

Answer 19

RLQ ab pain with possible vomiting

Question 20

Bacterial PNA

Answer 20

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

Question 21

Pyelonephritis

Answer 21

vomiting may be seen that leads to dehydration

- distinguish frequency from polyuria

Question 22

Further studies with newly diagnosed diabetes

Answer 22

autoimmune thyroid disease and celiac disease

Question 23

Prioritize managing DKA

Answer 23

1. ABCs
2. Fluid bolus (20 mL/kg)
3. Blood glucose, CV monitor, UA, blood gas and electrolytes
4. Insulin administration (0.1 units/kg/hr)
5. Add potassium later
6. Admit to hospital
7. consult endo

Question 24

Admission orders for DKA

Answer 24

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

Question 25

Insulin therapy

Answer 25

Basal insulin and prandial insulin (start at 1 unit/kg/day)
Morning dose: 2/3 total dose
1/6 dose at dinner
1/6 dose before bed

Question 26

Honeymoon phase of insulin

Answer 26

within 1 month of diagnosis, requirement of insulin can be way down, but it doesn’t stay that way

Question 27

Education for patietn

Answer 27

Use all specialists, get them best education possible to manage diabetes effectively