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Pediatric Dka Case Scenario

Pediatric Diabetic Ketoacidosis

Pediatric Diabetic Ketoacidosis

Pediatric Diabetic Ketoacidosis Authors: Katia M. Lugo-Enriquez, MD, FACEP, Faculty, Florida Hospital Emergency Medicine Residency Program, Orlando, FL. Nick Passafiume, MD, Florida Hospital Emergency Medicine Residency Program, Orlando, FL. Peer Reviewer: Richard A. Brodsky, MD, Pediatric Emergency Medicine, St. Christopher's Hospital for Children, Assistant Professor, Drexel University, Philadelphia, PA. Children with diabetes, especially type 1, remain at risk for developing diabetic ketoacidosis (DKA). This may seem confounding in a modern society with such advanced medical care, but the fact remains that children who are type 1 diabetics have an incidence of DKA of 8 per 100 patient years.1 In fact, Neu and colleagues have noted in a multicenter analysis of 14,664 patients in Europe from 1995 to 2007 that there was no significant change in ketoacidosis presenting at diabetes onset in children.2 In children younger than 19 years old, DKA is the admitting diagnosis in 65% of all hospital admissions of patients with diabetes mellitus.3 This article reviews the presentation, diagnostic evaluation, treatment, and potential complications associated with pediatric DKA. — The Editor Introduction The overall mortality rate for children in DKA is not unimpressive: The range is 0.15% to 0.31%.4 Besides death, one of the most feared repercussions of DKA in children is cerebral edema, an entity that occurs approximately 1% of the time.5,6 Cerebral edema, with the exception of a few case reports in some young adults, has largely been a complication of treatment in the pediatric population, and the exact factors have yet to be completely determined. The mortality associated with cerebral edema may approach 20% to 50%, and the incidence of neurologic morbidity is significant and Continue reading >>

Diabetic Emergencies, Part 5: Dka Case Studies

Diabetic Emergencies, Part 5: Dka Case Studies

Case Study 1 A 32-year-old male with type 1 diabetes since the age of 14 years was taken to the emergency room because of drowsiness, fever, cough, diffuse abdominal pain, and vomiting. Fever and cough started 2 days ago and the patient could not eat or drink water. He has been treated with an intensive insulin regimen (insulin glargine 24 IU at bedtime and a rapid-acting insulin analog before each meal). On examination he was tachypneic, his temperature was 39° C (102.2° F), pulse rate 104 beats per minute, respiratory rate 24 breaths per minute, supine blood pressure 100/70 mmHg; he also had dry mucous membranes, poor skin turgor, and rales in the right lower chest. He was slightly confused. Rapid hematology and biochemical tests showed hematocrit 48%, hemoglobin 14.3 g/dl (143 g/L), white blood cell count 18,000/ μ l, glucose 450 mg/dl (25.0 mmol/L), urea 60 mg/dl (10.2 mmol/L), creatinine 1.4 mg/dl (123.7 μ mol/L), Na+ 152 mEq/L, K+ 5.3 mEq/L, PO4 3−2.3 mEq/L (0.74 mmol/L), and Cl− 110 mmol/L. Arterial pH was 6.9, PO 2 95 mmHg, PCO 2 28 mmHg, HCO 3−9 mEq/L, and O 2 sat 98%. The result of the strip for ketone bodies in urine was strongly positive and the concentration of β-OHB in serum was 3.5 mmol/L. Urinalysis showed glucose 800 mg/dl and specific gravity 1030. What is your diagnosis? The patient has hyperglycemia, ketosis, and metabolic acidosis. Therefore, he has DKA. In addition, because of the pre-existing fever, cough, localized rales on auscultation and high white blood cell count, a respiratory tract infection should be considered. The patient is also dehydrated and has impaired renal function. Do you need more tests to confirm the diagnosis? Determination of the effective serum osmolality and anion gap should be performed in all patients presenti Continue reading >>

Dka | Modules | Iu Pcome

Dka | Modules | Iu Pcome

If blood sugar falls below 300, add 5% dextrose to fluids It may be necessary to use 10% or 12.5% dextrose fluids if glucose continues to fall Blood glucose monitoring should be performed hourly! This is to monitor for overly rapid drop in blood glucose and osmolality Osmolality=2 (Na+K) + (Glucose/18) + (BUN/2.8) Bolus insulin (subcutaneous/IV) is not recommended Bolus insulin has been shown to be unnecessary in pediatric patients and may increase the risk of cerebral edema (Lindsay 1989, Edge 2005) Insulin infusion at 0.1 unit/kg/hr after initial fluid resuscitation has been completed (may be started after at least 1-2 hours) Smaller dose of insulin (0.05 unit/kg/hr) may be used in smaller children Hemoglobin A1C, blood hydroxybutyrate concentration Sodium bicarbonate is not recommended in pediatric DKA! Evidence does not justify the administration due to possible clinical harm and lack of sustained benefits (Chua 2011) Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents: a consensus statement from the American Diabetes Association. Diabetes Care. 2006. 29(5)1150-1159. Bohn D, Daneman D. Diabetic ketoacidosis and cerebral edema. Curr Opin Pediatr. 2002. 14:287-289. Lindsay R, Bolte RG. The use of an insulin bolus in low-dose insulin infusion for pediatric diabetic ketoacidosis. Pedaitr Emerg Care. 1989. 5:77-79. Edge J, Jakes R, et al. The UK prospective study of cerebral oedema complicating diabetic ketoacidosis. Arc Dis Child. 2005. 90(Suppl 11):A2-A3. Chua HR, Schneider A, Bellomo R. Bicarbonate in diabetic ketoacidosisa systematic review. Ann Int Care. 2011; 1:23. Continue reading >>

25-40% Of Newly Diagnosed Cases Present In Dka

25-40% Of Newly Diagnosed Cases Present In Dka

Case Scenario #1 What is your assessment? DKA exists when: Venous pH < 7.3 Serum bicarbonate < 15 mEq/dL Blood glucose > 300 mg/dL Presence of ketonemia/ketonuria How much fluid would you administer as a bolus? Would you administer bicarbonate? How much insulin would you administer? What IVF would you start? At what rate? * 10 - 20 cc/kg bolus of NS would be adequate. Though the patient is dehydrated (dry lips), his hemodynamics are good, with acceptable vitals and good perfusion. There would be no reason to administer more than 20 cc/kg fluids. While this patient is clearly acidemic, he is NOT in impending cardiovascular collapse and therefore there is no justification for the administration of bicarbonate. In fact, administration of bicarbonate has been associated with the development of cerebral edema. The “true†serum sodium is 143 133 + 0.016[700-100] Insulin is generally started at 0.1 u/kg/hr. Therefore, in this 30 kg patient, an insulin infusion of 3 u/hr of regular insulin should be initiated. IVF of NS should be started at ~ 2400 cc/m2/day, which is approximately 1.5 x maintenance Continue reading >>

Acute Management Of Pediatric Diabetic Ketoacidosis

Acute Management Of Pediatric Diabetic Ketoacidosis

Acute Management of Pediatric Diabetic Ketoacidosis To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications. Introduction: This educational tool is a PowerPoint presentation that allows providers to quickly access guidelines for acute management of pediatric diabetic ketoacidosis (DKA). It was created after a chart review of pediatric patients with DKA determined that guidelines of DKA management were being incompletely followed. Methods: The resource contains recommendations from the American Diabetes Association guidelines, as well as a learning module consisting of a case scenario and three questions, each of which highlights important aspects of the care of pediatric patients with DKA.Session length should be no longer than 15 minutes. Results: Data are currently being collected on the reach of this educational tool. Discussion: The resource is limited by its short duration. It was deliberately designed to be readily accessible in a time-limited situation for initial care. Part of the education focuses on the complexity of pediatric patients with DKA, in the process making it clear that the three questions highlight only the most immediate clinical need. As a tool to be used in an acute care setting, this resource is adequate; however, a more comprehensive module with more detailed recommendations could be constructed for learners with less clinical experience. Barrios EK, Hageman J, Lyons E, et al. Current variability of clinical practice management of pediatric diabetic ketoacidosis in Illinois pediatric emergency departments. Pediatr Emerg Care. 2012;28(12):1307-13 Continue reading >>

Pardon Our Interruption...

Pardon Our Interruption...

As you were browsing something about your browser made us think you were a bot. There are a few reasons this might happen: You're a power user moving through this website with super-human speed. You've disabled JavaScript in your web browser. A third-party browser plugin, such as Ghostery or NoScript, is preventing JavaScript from running. Additional information is available in this support article. After completing the CAPTCHA below, you will immediately regain access to Continue reading >>

Diabetic Ketoacidosis And Pediatric Stroke

Diabetic Ketoacidosis And Pediatric Stroke

THE CASE: A 6-year-old previously healthy right-handed girl presented with a 3-day history of progressive epigastric abdominal pain, polydipsia and secondary nocturnal enuresis and a 2-week history of weight loss of 5 kg. Her initial assessment revealed tachypnea with Kussmaul's respiration, tachycardia and moderate dehydration, with an estimated fluid deficit of 6%– 9%. The girl was hyperglycemic (plasma glucose level 43.4 mmol/L) and acidotic (pH 7.13, bicarbonate level 3.8 mmol/L), with urinalysis revealing ketonuria and glucosuria. After admission, appropriate fluid resuscitation and insulin treatment were started. The patient's diabetic ketoacidosis resolved over 20 hours, at which point a diabetic diet was introduced along with subcutaneous insulin therapy. On the morning after admission, the patient was found by the nursing staff to be irritable, lethargic and intermittently combative. Twelve hours later a right hemiparesis and aphasia became evident. A cranial CT scan showed an evolving infarct in the left basal ganglia. Transcranial Doppler ultrasonography and magnetic resonance angiography showed occlusion of the proximal left middle cerebral artery (Fig. 1). Echocardiography showed 2 thrombi, measuring 11 х 9 mm and 1 х 1 mm respectively, on the underside of the anterior mitral valve leaflet. There was no associated congenital heart disease. Because of a high risk of further thromboembolic events, heparin infusion was begun, and open thrombectomy was performed on the third day. Pathological examination revealed inflammatory cells and an organized thrombus. Blood cultures and prothrombotic studies yielded negative findings. Intensive rehabilitation therapy and low-molecular-weight heparin (enoxaparin, 30 mg subcutaneously every 12 hours) were started after Continue reading >>

Pediatric Dka | Em Sim Cases

Pediatric Dka | Em Sim Cases

Peer-reviewed simulation cases for Emergency Medicine programs available in FOAMed spirit. This case is written by Dr. Donika Orlich.She is an Emergency physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University and also obtained a fellowship in simulation and medical education during her training. DKA is a reasonably common presentation to the ED. However, it requires several important steps in its management in order to prevent harm. This is especially true in children, where the rates of cerebral edema are higher. This case highlights several important features in the management of Pediatric DKA, including: That there is no role for an insulin bolus. That the precipitant of DKA must always be considered (in this case, it is appendicitis) That cerebral edema is a known complication of DKA and must be managed immediately with a reduction in the insulin and fluid rates as well as with either mannitol or hypertonic saline We have previously published a case of Pediatric DKA on emsimcases. Todays case is unique in that it begins with the learners providing advice over the phone to a physician who is less comfortable managing DKA. We have chosen to publish on this topic a second time as a way to emphasizes how cases on the same topic can be designed with different objectives in mind. The objectives (and therefore the case design) can lead to very different learning experiences. We have no doubt that this new case will also lead to excellent debriefing and evidence review with learners it certainly does when we run it for our senior residents at McMaster University! The learners receive a call from a peripheral hospital about transferring an unwell 8-year-old girl with new DKA. She has been incorrectly managed, re Continue reading >>

Case Based Pediatrics Chapter

Case Based Pediatrics Chapter

This is a 9 year old boy who has enjoyed his usual state of good health until his polyuria started 2 months ago. He began to lose weight and reported worsening nocturia over this same period. His appetite increased although lately he has more episodes of stomachaches. Today, he had a noticeably sweet smell to his breath and he was breathing faster than usual so his mother brought him to his pediatrician. Exam: VS T 37.0, RR 44, P 92, BP110/60, oxygen saturation 100% on room air. His weight was 25 kg (25%tile). He is alert and cooperative. His skin is warm to his wrists and ankles. His oral mucous membranes are tacky. His capillary refill is 3 seconds over his chest. His skin was otherwise normal. His thyroid gland is approximately 1.5 times the normal size. His heart rate is regular. He is slightly tachypneic with clear breath sounds. His reflexes are normal. His abdomen has normal bowel sounds has no tenderness. His genitalia and pubic hair are in Tanner stage I. The rest of the physical examination is unremarkable. His pediatrician suspects new onset diabetes mellitus. A urine dipstick in the office shows 4+ glucose and 2+ ketones. No other dipstick abnormalities are noted. He is clinically stable. He is hospitalized for further management and treatment. His initial lab studies show Na 132, K3.3, Cl 99, bicarb 11, glucose 380, BUN 21, creatinine 0.4. He is started on an IV fluid infusion and subcutaneous insulin. Prior to the purification of insulin, type 1 diabetes mellitus was uniformly lethal. Although we have made significant strides in the evaluation and management of diabetes, it remains a significant health problem in the general population. In the pediatric subset of the population, type 1 diabetes mellitus is especially challenging since so many factors need Continue reading >>

Peer Reviewers

Peer Reviewers

Pediatric Diabetic Ketoacidosis: An Outpatient Perspective On Evaluation and Management Abstract Diabetic ketoacidosis is a common, serious acute complication in children with diabetes mellitus. Diabetic ketoacidosis can accompany new-onset type 1 diabetes mellitus or it can occur with established type 1 diabetes mellitus during the increased demands of an acute illness or with decreased insulin delivery due to omitted doses or insulin pump failure. Additionally, diabetic ketoacidosis episodes in children with type 2 diabetes mellitus are being reported with greater frequency. Although the diagnosis is usually straightforward in a known diabetes patient with expected findings, a fair proportion of patients with new-onset diabetes present in diabetic ketoacido- sis. The initial management of children with diabetic ketoacidosis frequently occurs in an emergency department. Physicians must be aware that diabetic ketoacidosis is an important consideration in the differential diagnosis of pediatric metabolic acidosis. This review will acquaint emergency medicine clinicians with the pathophysiology, treatment, and potential complications of this disorder. Author William Bonadio, MD Attending Physician, Pediatric Emergency Medicine, Maimonides Medical Center, Brooklyn, NY Arleta Rewers, MD, PhD Associate Professor of Pediatrics, University of Colorado, Denver, School of Medicine, Aurora, CO Joseph I. Wolfsdorf, MD Clinical Director, Division of Endocrinology, Boston Children’s Hospital, Professor of Pediatrics, Harvard Medical School, Boston, MA CME Objectives Upon completion of this article, you should be able to: 1. Describe the pathophysiology of DKA and the associated clinical signs and symptoms of this disorder. 2. Discuss management of DKA to restore metabolic hom Continue reading >>

High Fidelity Simulation Case: Teaching Diabetic Ketoacidosis With Cerebral Edema

High Fidelity Simulation Case: Teaching Diabetic Ketoacidosis With Cerebral Edema

High Fidelity Simulation Case: Teaching Diabetic Ketoacidosis with Cerebral Edema To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications. Diabetic ketoacidosis is a common complaint throughout the emergency departments of the United States. However, the subsequent development of cerebral edema is a rarely encountered and critical clinical entity. Though residents and medical students have a great deal of exposure through their clinical time to diabetic ketoacidosis, very few have the opportunity to witness the development of cerebral edema and aid in its management. It is for this reason that this simulation has been developed to prepare the learner for the actual disease process should it occur. This simulation case goes through the recognition and management of this challenging condition. The learner should demonstrate expected competencies in the management of both clinical entities however the primary focus is in the simulation of the development and subsequent management of cerebral edema. This curriculum has been used by emergency medicine residents at SUNY Upstate in order to model a rare clinical entity to prepare them for their actual clinical encounters. The simulation case has been used by 30-33 residents with good success and very positive feedback. Continue reading >>

Case Presentation

Case Presentation

EM Registrar Case 12 year old male 1/12 fatigue Severe LOW 3/7 increasing SOB 1/7 confusion + lethargy Case Med Hx: Nil Chronic Medication: Nil Allergies: Nil known Multiple GP visits: fatigue due to puberty Case Clinically: Emaciated P 140 BP 70/40 RR 45 Temp 37.6°C Glucose: 36 mmol/l Acidotic breathing, shocked CNS – drowsy, but rousable, orientated to person, not place or time Other systems essentially normal Case Urine Ketones + UEC 129/ 5,2/ 9.3/ 108 ABG pH 7.05 pCO2 1.8 pO2 18 Bicarb 5.2 BE – 20 Case Problems New Type I DM DKA Hypovolaemic Shock Hyponatraemia Cerebral Oedema Management First bolus: 10ml/kg N/Saline – remained hypotensive Second bolus 10ml/kg N/Saline: still hypotensive, but ↑ confusion Concern about worsening cerebral oedema Fluid boluses stopped, commenced on fluid rehydration 0.45% Saline Admitted to ICU CT Brain: cerebral oedema Worsened over next 48 hrs, but eventually made complete recovery Case Type of fluid? Volume for resuscitation? Management of cerebral oedema in DKA? Predictors of cerebral oedema in DKA? Type of Fluid Normal (0.9%) Saline Generally recommended fluid1 Concerns about hyperchloraemic acidosis2 Ringers Lactate3 More hypotonic → increased risk cerebral oedema Lactate potentially metabolised to glucose Non-metabolised lactate can ↓ level of consciousness Contains potassium No evidence to support other crystalloids/ colloids for resuscitation Very little evidence overall for different fluids Best evidence for 0.9% Saline4 If not available, isotonic fluid Consider 0.45% saline for rehydration if hypernatraemic Volume for Resuscitation ≤ 10ml/kg boluses repeat to max 3 doses (30ml/kg)1,5 Fluid bolus not required if not shocked Fluid deficit replacement over 24-48 hrs Lower fluid Continue reading >>

Current Variability Of Clinical Practice Management Of Pediatric Diabetic Ketoacidosis In Illinois Pediatric Emergency Departments

Current Variability Of Clinical Practice Management Of Pediatric Diabetic Ketoacidosis In Illinois Pediatric Emergency Departments

ObjectiveThis study aimed to investigate the management of pediatric patients with diabetic ketoacidosis (DKA) presenting to emergency departments (EDs) participating in the Illinois Emergency Medical Services for Children (EMSC) Facility Recognition program. MethodsIn 2010, Illinois EMSC conducted a survey (including case scenarios) and medical record review regarding management of pediatric patients with DKA. Data were submitted by 116 EDs. ResultsSurvey response rate was 94%. Only 34% of EDs had a documented DKA guideline/policy; 37% reported that they did not have hospital adult or pediatric endocrinology services. Case scenarios identified a high percentage of respondents given an intravenous (IV) isotonic sodium chloride solution of 10 to 20 mL/kg during the first hour. However 17% to 21% would use an alternative choice such as administering initial IV solution of 0.45 sodium chloride, initiating an insulin drip before fluids, or waiting for more laboratory results before giving fluids or insulin. A total of 532 medical record reviews were submitted. In 87% of records, patients received an initial IV isotonic sodium chloride solution within the first hour. In 74%, patients received IV insulin infusion/drip (0.1 U/kg/h) after the initial fluid bolus. Of the patients, 51% were transferred to another facility; 22% were admitted to an intensive care unit. ConclusionsBest ED practice management of pediatric DKA includes establishing a specific guideline/protocol and ensuring access to a pediatric endocrinologist. Both were identified as improvement areas in this project. Illinois EMSC has developed an educational module and provided direct feedback to all participating EDs, to improve their management of pediatric patients with DKA. From the *Lawndale Christian Health Continue reading >>

Pediatric Diabetic Ketoacidosisclinical Presentation

Pediatric Diabetic Ketoacidosisclinical Presentation

Pediatric Diabetic KetoacidosisClinical Presentation Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD more... When diabetic ketoacidosis occurs as a first presentation of diabetes, symptoms are likely to develop over several days, with progressive dehydration and ketosis. In a small child wearing diapers and with naturally high fluid intake, polyuria and polydipsia are easily missed. When diabetes is developing, the stress and symptoms of another illness may precipitate diabetic ketoacidosis, as well as mask the underlying problem. Diabetic ketoacidosis can develop very rapidly in a patient with established diabetes, particularly when insulin therapy has been forgotten, deliberately omitted, or disrupted, as with children on continuous subcutaneous insulin infusions or using the newer analogue insulins. Under these circumstances, diabetic ketoacidosis may present with relatively normal blood glucose levels (ie, 250 mg/dL, 15 mmol/L) or less. Symptoms of hyperglycemia include the following: Polyuria - Increased volume and frequency of urination Polydipsia - Thirst is often extreme, with children waking at night to consume large quantities of any available drink Nocturia and secondary enuresis in a previously continent child Weight loss - May be dramatic due to breakdown of protein and fat stores Symptoms of acidosis and dehydration include the following: Abdominal pain that may be severe enough to present as a surgical emergency; for children with a failure of continuous subcutaneous insulin infusion, this may be the first presenting sign, along with vomiting Shortness of breath that may be mistaken for primary respiratory distress Confusion and coma in the absence of recognized head injury [ 1 ] Presentation of cerebral ede Continue reading >>

Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario

Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario

DOI: 10.7759/cureus.1286 Cite this article as: Addison R, Skinner T, Zhou F, et al. (May 29, 2017) Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario. Cureus 9(5): e1286. doi:10.7759/cureus.1286 Abstract Simulation provides a safe environment where learning is enhanced through the deliberate practice of skills and controlled management of a variety of clinical encounters. This is particularly important for core cases and low-frequency, high-stakes procedures and encounters. Competency-based medical education has seen widespread adoption in the field along with ongoing work in the areas of undergraduate and postgraduate training. Similarly, effective professional development activities stand to benefit greatly from a more stringent integration of simulation and competency-based approaches. This particularly makes sense when considering the goals of patient safety and achievement of optimal clinical outcomes. The current report describes a simulation training session designed to acquaint emergency medicine residents with the presentation and management of diabetic ketoacidosis (DKA) through the use of simulation. Continue reading >>

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