The school nurse says it's the stomach flu

[chbare]

Looks like I missed the above post. I would hesitate to give bicarb to this patient. Remember she is most likely in a state of relative hyperkalemia, but in fact will require potassium supplementation. Without labs and serial potassium levels, we could cause a catastrophic drop in the patients potassium level if we administer bicarb.

In the early stages of DKA without labs, fluids are actually the primary treatment. In some cases of DKA, fluids alone will nearly correct the acidosis. Remember, this patient is severely dehydrated.

Take care,

chbare.

[Just Plain Ruff]

thats why I originally stated we wanted to get her to definitive treatment and some insulin.

I hesitated to give bicarb but one of the guys threw in Acidosis. So I started down the route of bicarb but after discussing with my mentors here I find that bicarb is a bad thing and there is a reason it's been a very very long time since I've given it for really anything.

I still stand by my original post of definitive treatment at a hospital for labs and more advanced treatment than we can give her in the ambulance. WE are pretty limited in this situation as to what we can give. Too bad we don't have access to labs. They will tell us almost everything we need to know.

But with the limited amount of diagnostic and medical equipment we carry on board for this type of patient, supportive care, fluid bolus's of 20ml/kg and rapid but smooth transport of this really really sick little girl is about the best we can do.

Hey Doc, how far are we away from the hospital now?

[chbare]

We can still consider giving a little dextrose IV and see if this helps.

Take care,

chbare.

[Dustdevil]

Did my partner give any medications?

:shock:

[ERDoc]

what are her pupils like?

so I guess the original hospital is the place to go.

the helicopter will get her to the hospital about the same time you can get her there so it's ground transport.

So what are the roads like between us and the receiving facility?/ are they closed due to some tractor trailer cow transport crash or something like that?

I think we need to look at the amount of fluid we are pushing in to this girl. What are her lungs sounding like with that liter of fluid?

Let's get on the horn to the hospital and discuss this case with them. Or are the phones out in the area?

AS for her pupils - these are key for cerebral edema

How much does she weigh? We need a 20ml/kg bolus of fluid to start with. Then we can back that off as needed.

But in all the research and info I'm seeing is that the definitive treatment for this little girl is insulin.

The roads are fine (but I like your thinking). Her lungs are clear. Your partner has given her a little over a liter. The pt weighs about 35 kg. Pupils are equal. Why would this pt have cerebral edema? You are out in the middle of nowhere. There is no reliable cellular service and the radios don't reach far enough.

[ERDoc]

Initial BGL was 525, the current BGL is 370. This gives us a delta of 155 in 15 minutes. We typically do not want to drop BGL's by more than 100mg/dl/hour. I suspect cerebral edema. We have aggressively changed the osmolarity of the intravascular space with an isotonic solution as evidenced by the rapid drop in sugar. However, the intracellular space is still hyperosmolar compared to the intravascular space and water will move with the gradient. I have never seen this occur with a change in 155mg/dl; however, such a sudden change in this particular patient may be enough.

We may need to bring her sugar up a bit. I would try to stay away from intubating a DKA patient if possible. We can really screw acid base/electrolyte balance up when we intubate a DKA patient and her vent settings will need close monitoring.

Did my partner give any medications?

Take care,

chbare.

Other than the fluids, your partner did not give anything. No matter how much sugar you give, the pt does not respond. You are on the right track however.

[ERDoc]

thats why I originally stated we wanted to get her to definitive treatment and some insulin.

I hesitated to give bicarb but one of the guys threw in Acidosis. So I started down the route of bicarb but after discussing with my mentors here I find that bicarb is a bad thing and there is a reason it's been a very very long time since I've given it for really anything.

I still stand by my original post of definitive treatment at a hospital for labs and more advanced treatment than we can give her in the ambulance. WE are pretty limited in this situation as to what we can give. Too bad we don't have access to labs. They will tell us almost everything we need to know.

But with the limited amount of diagnostic and medical equipment we carry on board for this type of patient, supportive care, fluid bolus's of 20ml/kg and rapid but smooth transport of this really really sick little girl is about the best we can do.

Hey Doc, how far are we away from the hospital now?

There is no lab test that will help this girl immediately. This diagnosis and treatment are based on what you see clinically. A CT might help, but if you wait for it, it may be too late. You are now about 10 minutes out from the peds center but still no radio contact and your partner forgot to charge the cell phone.

[Just Plain Ruff]

well first off the starting dose of fluid replacement is 20cc/kg which by my estimation my newbie partner has given her 1.5 times the amount she should originally get.

Here is what I found about cerebral edema which apparantly is much more common in kids than adults so we have to be extravigilant in kids. You never did tell me what the pupils were?

Cerebral edema is a rare but important complication of DKA. Although it can affect adults, it is more common in young patients, occurring in 0.7 to 1.0 percent of children with DKA.3 Early signs of cerebral edema include headache, confusion, and lethargy. Papilledema, hypertension, hyperpyrexia, and diabetes insipidus also may occur. Patients typically improve mentally with initial treatment of DKA, but then suddenly worsen. Dilated ventricles may be found on CT or magnetic resonance imaging. Treatment of suspected cerebral edema should not be delayed for these tests to be completed. In more severe cases, seizures, pupillary changes, and respiratory arrest with brain-stem herniation may occur. Once severe symptoms occur, the mortality rate is greater than 70 percent, and only about 10 percent of patients recover without sequelae.3

Avoiding overhydration and limiting the rate at which the blood glucose level drops may reduce the chance of cerebral edema.3 However, some patients may present with cerebral edema before treatment is started. About 10 percent of the patients initially diagnosed with cerebral edema have other intracranial pathology such as subarachnoid hemorrhage.43 Mannitol (Osmitrol) therapy and hyperventilation have been recommended based on limited evidence.44,45

Source - http://www.aafp.org/afp/20050501/1705.html

[Just Plain Ruff]

reading more on cerebral edema this kid sounds like we've given it to her on a silver platter.

I think we may not have any choice other than to intubate her.

from the same article cited ---- Once severe symptoms occur, the mortality rate is greater than 70 percent

How bout some mannitol if we suspect cerebral edema -

Same article -- About 10 percent of the patients initially diagnosed with cerebral edema have other intracranial pathology such as subarachnoid hemorrhage.43 Mannitol (Osmitrol) therapy and hyperventilation have been recommended based on limited evidence

So if she indeed has cerebral edema, we need to tube her and begin to assist ventillations even to the point of hyperventillation. The mannitol will help reverse the fluid imbalance in her head.

Again, I'm going to kick myself after the call due to letting my newbie partner take care of such a critical patient.

So my guess is that she already was suffering from the beginning stages of cerebral edema even before we made contact with her. The signs and symptoms are all there.

Of course I may be off base and way out of town on this one but I think that we have done more damage to this kid than we think we have.

[chbare]

This is where the signs and symptoms point. At this point we may be forced to perform ET intubation. We will need to hyperventilate this patient, not only because of increased ICP, but because we will most likely need to keep her C02 lower than normal related to her underlying metabolic acidoses. Many DKA patients will have a compensatory respiratory alkalosis and if we ventilate with "normal" setings we could really screw this one up. In addition, we may need to consider Mannitol in the range of about 0.3-1 g/kg IV gtt.

Take care,

chbare.