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Huda

Huda

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    Case presentation Case presentation Presentation Transcript

    • Case presentation
      Huda Al-Shibli
      E.M.
      R1
    • Outline;
      Case presentation
      Discussion
      take home massages
    • 4 yr-old child
      2 day-h/o abdominal pain, loose motion and vomiting
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    • 1 survey
      A: patent
      B: normal, RR 35, sPO2 97% in RA,
      C: P 110, BP 100/84, T 37.0 c
      D: GCS; 15/15, pupils 2 mm reacting b/l,
      E: NAD
      Wt : 13 kg
      What do you want to do ?
    • History
      Abdominal pain X 2 days
      associated with vomiting 5 times /day , small to moderate amount , non projectile ,
      Loose motion 5 times /day , small amount semisolid , no blood or mucous
      Child is less active , not feeding well
      h/o cough and cold during the last week and now improved
      No h/o fever
      No past h/o medical problem
    • 2 survey
      O/E :
      Small boy , looks unwell, tachypnic , but alert and responding
      Not jaundiced or pale
      Dry mucous membrane
      Capillary refilling 3 sec
      ears : clear
      Throat : mild congestion and mild enlarged tonsils
      Chest ….. Clear
      CVS …… S1+S2, no gallop, no murmur
      Abdomen: soft with ?epigastric tenderness, BS +ve, no hepto-splenomegaly
      CNS :no neurologic deficit, no meningeal signs .
    • What is your impression?
      What is your next step ?
    • Impression : gastroenteritis with moderate dehydration ( 5-7%)
      Plan :
      Blood investigations: cbc, ue1
      IVF 20 ml /kg NS bolus , then dextrose saline 0.45 % @100 ml/hr + kcl 10 mmol/500 ml
      To give ondasterone and try oral intake
      Reassess later
    • Reassessment
      After 1 hour :
      The child looks unwell
      Not active , but still alert and responding
      RR 37
      Capillary refilling 3 sec
      The mother said he is drinking good amount of water but he vomited 3 times and had one small amount of loose stool.
    • Investigations
      Lab :
      Cbc
      Hb : 12
      WCC: 12
      UE1
      130:Na
      K: 4.0
      13:Hco3
      Urea and creatinine :WNL
    • It was the end of the shift
      The case handed over to the next coming team
      After reassessment , they sent VBG and showed pH of 7.2 and they check reflow it was 16 mmol/l
      So it was DKA and they started management
    • DKA
    • DKA is the leading cause of morbidity and mortality in children with T1DM ranging from 0.15 % to 0.31 % .
      In addition, DKA also can occur in children with T 2 DM; this presentation is most common among youth of African-American descent.
    • DEFINITION 
       Consensus statements from the European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society in 2004, the American Diabetes Association in 2006, and the International Society for Pediatric and Adolescent Diabetes in 2007 defined the following biochemical criteria for the diagnosis of DKA :
      1-Hyperglycemia, defined as a blood glucose of >200 mg/dL (11 mmol/L) AND
      2-Metabolic acidosis, defined as a venous pH <7.3 and/or 3-a plasma bicarbonate <15 meq/L (15 mmol/L)
    • Take home messages
      1-Not every loose motion and vomiting is a GE.
      2-If a dehydrated child not responded to fluid therapy , and it is unlikely to be sepsis , ask yourself : is it a DKA ?
      3-check reflow for pt with ketone positive in the urine .