Scenario #1: A sick little girl

[usalsfyre]

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?

 

[Shishkabob]

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.

 

[taporsnap44]

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.

 

[Shishkabob]

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

 

[rescue99]

Sepsis also comes to mind.

 

[redcrossemt]

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.

 

[Shishkabob]

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.

 

[Smash]

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.

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.

 

[Shishkabob]

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

 

[DV_EMT]

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

 

[Smash]

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.

 

[Akulahawk]

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

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.