# Scenario #1: A sick little girl



## taporsnap44 (Oct 5, 2009)

Being a paramedic student, I always seem to learn a lot from scenarios. So with that said, I believe doing scenarios with a lot of input from various members at different training levels will be an exceptional learning tool. So here is the first one.

Date and Time: Monday, October 05, 2009 at 1900
Scenario: Dispatched for 9 YO F unresponsive

Arrive on Scene and the dad meets you out front, he is worried but not frantic, he leads you inside to his 9 YO daughter who is lying on the couch in a daze. She is awake but she is sluggish in her movements. 

History – No medical history	
Medications – No medications
Allergies – NKDA

Father’s statement - The farther states that she began feeling bad about 3 days ago and it has progressively gotten worse. He states that she has only had Pedialite and toast since Friday which she has vomited up most of the time. He also states that she has been complaining that her stomach hurts. He says that he had called her pediatrician who diagnosed her over the phone with a virus.  He then tells you that he went to work this morning and left her with her grandmother and when he got back, something just was not right and that’s why he called.

Assessment – Alert and oriented but sluggish, Skin – hot and dry, Blood pressure 90/palp, Pulse – 130, Respirations – deep and labored, SpaO2 94% on RA.

Proceed with a differential diagnoses and possible treatment plan. If you ask questions I will fill them into the assessment.


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## amberdt03 (Oct 5, 2009)

taporsnap44 said:


> Being a paramedic student, I always seem to learn a lot from scenarios. So with that said, I believe doing scenarios with a lot of input from various members at different training levels will be an exceptional learning tool. So here is the first one.
> 
> Date and Time: Monday, October 05, 2009 at 1900
> Scenario: Dispatched for 9 YO F unresponsive
> ...






what is her temp, lung sounds, and glucose level?


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## redcrossemt (Oct 5, 2009)

amberdt03 said:


> what is her temp, lung sounds, and glucose level?



Agreed - additional assessment of temperature (core if possible), lung sounds, blood glucose level, pupils, and ecg. Would also like to know about urine output, as well as if any OTCs have been given for the pain or fever.

Without additional information, my initial treatment thoughts consist of supplemental oxygen and a fluid bolus. Possibly acetaminophen as well for the fever. My bet is hypovolemia secondary to an infection and limited intake.


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## Smash (Oct 5, 2009)

Temp. Blood glucose and ketones. Breath sounds. Any smell on her breath? ECG. Pupils. Neuro assessment. Any signs of meningism? Any family history of diabetes?  Any history of polyuria, polyphagia or polydipsia?  Bowel motions? Any medications taken/given?  Any access to medications, legal or ortherwise?

Pending more detail I'd be leaning towards DKA, possibly secondary to an infective process. 

Oxygen, IV, bolus fluid, transport. Watch conscious state, consider intubation if pt tiring or GCS dropping. If inubated, maintain EtCO2 at pre intubation levels.

Keep a close eye on monitor at all times.


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## DV_EMT (Oct 5, 2009)

I'd like lung sounds and urine output as well. And the fever temp if one is present?


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## MrBrown (Oct 5, 2009)

Here's what I am thinking 

Hot, dry skin - fever and dehydration 
Deep, laboured resps - trying to excrete excess CO2
ALOC - rising level of CO2
Tachycardic - possibly one of the ubiquidose 400 causes, sign of physiological stress


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## Akulahawk (Oct 5, 2009)

At this point, I'm thinking what you've got on your hands is a 9 YO that is likely hot, dry, and sluggish from an infective process... possibly the flu. I'd also be concerned about a small bowel obstruction...

Neuro: alert & oriented... but sluggish. Nuchal rigity?
Eyes: PERRLA?
Lungs: unk
Cardiac: pulse 130. heart sounds? unk
abd: complains of pain. tenderness? rebound tenderness? sounds?
glucose: unknown
Bathroom: urine output? last observed BM?

My tx for now: O2 by NC, IV fluid bolus (20mL/kg), if the 9 YO is too hot - APAP if allowed locally. D25 or D50 (per protocol) PRN if hypoglycemic. Transport C2 to facility of parent's choice. Reassess frequently during transport.

This kid looks "sick" but (so far) not scoop & run C3 sick, based on what's known so far.

The above plan WILL LIKELY change based on additional reported findings...


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## taporsnap44 (Oct 6, 2009)

Temperature: 101* orally
Lung sounds: Clear and equal bilaterally
BGL: Reads HI
Pupils: PERL
ECG: Sinus Tach
Urine output: Farther states she has been urinating more than usual even with not eating or drinking much over last 3 days.

No smell on her breath.

Abdominal assessment: Tender in all 4 quadrants w/ active bowel sounds.

Grandmother confirms family h/x of diabetes.


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## MrBrown (Oct 6, 2009)

I'm going with DKA


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## DV_EMT (Oct 6, 2009)

Well if her lungs weren't clear... I would gone with bilateral pneumonia. But now idk what... I think dka is a possibility


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## rescue99 (Oct 6, 2009)

taporsnap44 said:


> Temperature: 101* orally
> Lung sounds: Clear and equal bilaterally
> BGL: Reads HI
> Pupils: PERL
> ...



The magic answers that give a possible diagnosis away.....diffuse abdominal pain and frequent urination.


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## SoCal (Oct 6, 2009)

possibly HHNK? 

I know HHNK is seen in older Type 2 Diabetics however, with no keytones on the breath and the BGL of HI, you could be possibly dealing with a sick little girl. Pts. presenting with HHNK are severely dehydrated and develops over time and results in polyuria, polydipsia, tachycardia, and dry membranes just like DKA. Also HHNK will lead to lethargy and confusion. 

Just my guess....


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## rescue99 (Oct 6, 2009)

SoCal said:


> possibly HHNK?
> 
> I know HHNK is seen in older Type 2 Diabetics however, with no keytones on the breath and the BGL of HI, you could be possibly dealing with a sick little girl. Pts. presenting with HHNK are severely dehydrated and develops over time and results in polyuria, polydipsia, tachycardia, and dry membranes just like DKA. Also HHNK will lead to lethargy and confusion.
> 
> Just my guess....



DI is another possibility...


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## SoCal (Oct 6, 2009)

That's true^^ possibly undiagnosed till now?


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## usalsfyre (Oct 6, 2009)

HHNK is possible due to the posibility of an infective process, but I'd go with DKA until proven otherwise. Family hx of diabetes, IDDM or NIDDM? A DI pt is probably not going to present as "HI" on a glucometer. 

As of now treatment plan is an initial fluid bolus followed by maintnance, standard airway monitoring, and transport to a pediatric center by whatever method is practical.


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## MrBrown (Oct 6, 2009)

So do we have a *proper* BGL rather than just the monitor says "high" ??

I'd go with 10ml/kg fluid bolus and transport


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## rescue99 (Oct 6, 2009)

usalsfyre said:


> HHNK is possible due to the posibility of an infective process, but I'd go with DKA until proven otherwise. Family hx of diabetes, IDDM or NIDDM? A DI pt is probably not going to present as "HI" on a glucometer.
> 
> As of now treatment plan is an initial fluid bolus followed by maintnance, standard airway monitoring, and transport to a pediatric center by whatever method is practical.



You are probably correct. Glucose probably won't be high. New onset IDM is most likely going to be the dx. Just had throw _all_ potentials into the ring. 1 hour at the ER and they'll have the correct diagnosis.


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## triemal04 (Oct 6, 2009)

usalsfyre said:


> HHNK is possible due to the posibility of an infective process, but I'd go with DKA until proven otherwise. Family hx of diabetes, IDDM or NIDDM? A DI pt is probably not going to present as "HI" on a glucometer.
> 
> As of now treatment plan is an initial fluid bolus followed by maintnance, standard airway monitoring, and transport to a pediatric center by whatever method is practical.


If I'm remembering right pancreatitis can cause or contribute to HHNK if the pt allready has underlying NIDDM; could help to explain the abdominal pn, though it's usually more specific than reported. 

Even with the lack of an odor on the pt's breath, the rapid/deep respirations are more indicative of ketoacidosis, which won't be seen in HHNK. 


MrBrown said:


> So do we have a *proper* BGL rather than just the monitor says "high" ??
> 
> I'd go with 10ml/kg fluid bolus and transport


The vast majority of glucose meters seen outside a lab will not read higher than 500 or in some cases 600mg/dL and lower than 10mg/dL.  What's the upper limit in New Zealand?


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## MrBrown (Oct 6, 2009)

triemal04 said:


> The vast majority of glucose meters seen outside a lab will not read higher than 500 or in some cases 600mg/dL and lower than 10mg/dL.  What's the upper limit in New Zealand?



Ours go up to 33 mmol/l but i have never seen it that high


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## triemal04 (Oct 6, 2009)

MrBrown said:


> Ours go up to 33 mmol/l but i have never seen it that high


So about the same as the ones used here.  Curious, what about the lower limit?  Numbers aside, the point is that getting a "proper" cbg reading may not be possible with the equipment available.  Of course, as long as you know your equipment this isn't a issue; "low" means VERY low, and "high" means VERY high; treat accordingly.


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## usalsfyre (Oct 6, 2009)

Most meters hit "TILT" at 500. As was stated before treat for severe hyperglycemia and don't forget it took a couple of days to get here so don't try to correct it overnight. 

Bonus, can anyone explain why it is or isn't approprite to treat the acidemia with sodium bicarbonate?


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## Shishkabob (Oct 6, 2009)

My money is more on HHNK considering the longer onset time of HHNK as opposed to DKA which is about a day, and considering she is currently sick "with a virus"... but even with that, DKA vs HHNK doesn't really matter in the field considering we treat both with the same tx.  You said deep respiration, but I didn't see an actual number so as such can't tell if it's kussmauls, or some other process going on.  

The 94% doesn't bother me, but I'd also want to see an EtCO2 waveform just to rule out/in respiratory alkalosis / acidosis.


O2 NC, 2-4lpm
IV
Fluid bolus, assess lung sounds, then another bolus--- she is dehydrated afterall

Transport to nearest facility.


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## taporsnap44 (Oct 6, 2009)

I do aplogize that was an oversight on my part, your monitor reads HI at 500. 

R/r counted at 22.

And everyone has pointed out the fact that there is not much we can do in the field either for HHNK or DKA other than treat dehydration. 

The one major clue is the nausea/vomiting thats not typically seen in HHNK.

To end the scnario -
The pt. was discharged from the ED as a type I diabetic. 

Just to note this was my first DKA pt. and I got tunnel vision on the whole "phone diagnosed virus". It wasn't until I checked the glucose and found the family history of IDDM.


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## Shishkabob (Oct 6, 2009)

I wouldn't call rr of 22 and deep Kussmauls for a pedi, but that's just me.


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## rescue99 (Oct 6, 2009)

Sepsis also comes to mind.


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## redcrossemt (Oct 6, 2009)

usalsfyre said:


> Bonus, can anyone explain why it is or isn't approprite to treat the acidemia with sodium bicarbonate?



Probably not appropriate in this case, but depends on the pH. There seems to be some consensus that bicarb is appropriate for extremely acidotic DKA patients. 

However, in general, fixing the hyperglycemia (with insulin) is the most important step in stopping the cascade that results in the build up of ketones and therefore acidosis. You also want to adequately hydrate this patient to keep the kidneys working and in turn excreting those ketones.


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## Shishkabob (Oct 6, 2009)

Mainly because we can't tell blood pH in the field and as such don't know how much / little to give.

And again, can't differentiate between HHNK and DKA in the field, and bicarb for HHNK is not a good thing.


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## Smash (Oct 6, 2009)

Linuss said:


> My money is more on HHNK considering the longer onset time of HHNK as opposed to DKA which is about a day, and considering she is currently sick "with a virus"... but even with that, DKA vs HHNK doesn't really matter in the field considering we treat both with the same tx.  You said deep respiration, but I didn't see an actual number so as such can't tell if it's kussmauls, or some other process going on.
> 
> The 94% doesn't bother me, but I'd also want to see an EtCO2 waveform just to rule out/in respiratory alkalosis / acidosis.
> 
> ...




Big ups to me for picking it first. But seriously, it's a classic textbook presentation of DKA.

EtCO2 will quite probably be low as she is clearly blowing off CO2 with that respiratory pattern. A big, nasty mistake that is sometimes made is that post intubation etco2 is allowed to return to 'normal' levels thus exacerbating the acidosis.  

HHNS/HHNK/HONK is really not something that would be much of an issue in this patient; as pointed out there is a very different demographic related to a different pathology to this. The lack of odour on the breath is by no means relevant: the odour may not necessarily be present, and even if it is, not everyone can smell it. Horses, not zebras.


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## Shishkabob (Oct 7, 2009)

What makes you think HHNK is a zebra?

No present kussmauls respirations
high, but undefined bgl
not a known diabetic, therefor don't know if it's IDDM or NIDDM
psyiological stress(often the cause of HHNK)

and the kicker
long term onset of symptoms


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## DV_EMT (Oct 7, 2009)

Smash said:


> Big ups to me for picking it first. But seriously, it's a classic textbook presentation of DKA.



true... but theres no sweet breath... which is a key symptom of DKA


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## Smash (Oct 7, 2009)

Linuss said:


> What makes you think HHNK is a zebra?
> 
> No present kussmauls respirations


. Rate alone does not rule out Kussmauls respirations. She is clearly demonstrating a respiratory pattern consistent with an attempt to correct acidosis. 


> high, but undefined bgl


. And?  Finger:censored::censored::censored::censored::censored: merely means it is above about 30mmols/l or thereabouts means nothing much either way. 


> not a known diabetic, therefor don't know if it's IDDM or NIDDM


. Very unlikely to be MODY: epidemiology suggests IDDM if nothing nothing else. It "could" be MODY but balance of probabilities suggest DKA. 


> psyiological stress(often the cause of HHNK)


physiological stress (often the cause of DKA - or is it a symptom? Hot and dry may not necessarily mean infective trigger but may in fact be part if the symptomology of DKA. Pts in DKA will almost always have leukocytosis as well so that cannot be used to determine if infection is the cause. It may be physiological stressors such as illness or injury, or it may even be psychological stressors that trigger the first episode of DKA in an undiagnosed diabetic) Goodness, that was a long parenthesisisisiisss. 



> and the kicker
> long term onset of symptoms



long term?  3 days is not long term by any stretch of the imagination. HONK is insidious in onset and is far more likely to evolve over weeks rather than days.  This is part of the reason why the mortality is so much higher, because osmolality and total water deficit is so much worse in a patient who is so much less able to tolerate it. DKA on the other hand fits beautifully with the onset, duration, symptoms and demographics of the patient.


Typed with my thumbs on my iPhone.


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## Akulahawk (Oct 7, 2009)

taporsnap44 said:


> Temperature: 101* orally
> Lung sounds: Clear and equal bilaterally
> *Resp Rate 22 and deep...*
> *BGL: Reads HI*
> ...


This changes my field dx. Like the others, with these findings, I'm also thinking DKA and let the ED determine DKA vs. HHNK. It also deletes APAP from my tx list... and makes me look at giving fluids to the patient as a high priority, and monitor lung sounds during/after each fluid bolus. Transport also becomes much more of an issue. I'd prefer to transport to a children's hospital, or one that does peds really well. While I might still transport C2, if the response to initial tx isn't good and I'm a ways away, I'd consider a C3 run.

The previous info + this info = this kid is very sick... though I don't think she'll crash right in front of me yet, based on what I see here... but that trainwreck is right around the corner, if not treated quickly.

Good to hear of the Type I DM dx on followup.


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