The school nurse says it's the stomach flu

[Just Plain Ruff]

I'm afraid we may have no choice but to tube her but Doc says that we are 10 minutes out or so.

I think if we ventillate her via BVM we can stave off intubation until the experts can get to her.

Her mortality rate with cerebral edema is about 70 percent and coming out of it with normal mentation and results is pretty slim.

Kid's always scare medics and emts and for good reasons. The only reason I've seen the need to tube kids are three fold.

1. The child needed it due to condition or arrest status.

2. We have missed something in our evaluation and exam and that item we missed was allowed to progress to the point of having a child in an obtunded state. And at that point we are behind the 8 ball and getting further and further behind. (this is the one you never ever ever want to have happen to you my friends)

3. We are correcting something that was missed by someone else.

There are others but the above are the ones that cause my pucker factor to get significantly worse.

This is a prime example of needing advanced education throughout your career. Don't rest on your laurels and think you don't need the education cause we all do.

So Doc, how did this turn out?

[chbare]

This is also why I will never advocate for insulin use pre-hospital. We can appreciate the nightmare if we had followed the "insulin protocol" and started running regular insulin at 0.1U/KG/hr on top of our fluid therapy.

All DKA patients are critical in my book. I remember a pediatrician tell a new onset DKA kid's mom and dad, "he may not look that bad on the outside, but he is very sick on the inside."

Take care,

chbare.

[Doczilla]

Nerve gas.

'zilla

[Scaramedic]

Ebola Zaire.

Peace,

Marty

[Doczilla]

Okay, I'll throw down the next pimp question here (tag team!). How much fluid do you want to give to her total. Do you want to push bicarb? Do you want to paralyze and intubate?

'zilla

[Asysin2leads]

Look its Dr. Cox...Sackie. Heh heh.

Anyway, I'm not for intubating just yet. Ruling out cerebral edema is not good enough cause in my book to start playing with the paralytics in a pediatric patient. I say, if the airway ain't compromised, leave it alone, but thats probably just the short trip 911 medic in me talking.

Secondly, lets not go crazy with fluids. She's dehydrated, okay, thats bad, we can replace some fluids, but I don't think it going to make a major difference in the patient's outcome. Remember, to half someone's BGL you'd have to double their total fluid volume, and if you did that, you'd probably cause a lot more problems then you'd solve.

The end answer for me is this. I don't know whats going on, but its something really bad and and something I probably can't fix with any of the equipment that is on a standard United States ALS ambulance. Maintain the BP, monitor the airway, drive very fast to the hospital.

And no, Doczilla, I don't know the reaction of sodium bicarbonate with the acidic bodies acetoacetate and beta-hydroxybutyrate produced in DKA. You got me. What happens? Is it good?

[chbare]

I would KVO her IV's for the moment and let the ER staff deal with calculating the fluid type and rate in 10 minutes.

I would not push bicarb with this patient. While it may be tempting to reverse her acidosis with bicarb, we would have to deal with the consequences of such an action. (Hypokalemia, increased Co2, etc.)

With a 10 minute time to the ER, I would hesitate to RSI. If we can control her airway adequately with BLS maneuvers, I will let the ER deal with it.

Sounds like a cop out dump job, shameless. I know.

Take care,

chbare.

[ERDoc]

I would KVO her IV's for the moment and let the ER staff deal with calculating the fluid type and rate in 10 minutes.

I would not push bicarb with this patient. While it may be tempting to reverse her acidosis with bicarb, we would have to deal with the consequences of such an action. (Hypokalemia, increased Co2, etc.)

With a 10 minute time to the ER, I would hesitate to RSI. If we can control her airway adequately with BLS maneuvers, I will let the ER deal with it.

Sounds like a cop out dump job, shameless. I know.

Take care,

chbare.

Sometimes the best thing to do is nothing. This girl is a new onset diabetic who is presenting with DKA (very common scenario). The whole thing with other kids being sick was just a red herring. In kids, if you give fluids too quickly you can cause cerebral edema. This is due to the shift in osmolality. For kids you want to give the standard 20cc/kg bolus. Your partner was a little over aggressive with his fluids. If you have a kid in DKA and you start to get mental status changes, think cerebral edema. Stop the fluids and if you have access to them you should give mannitol or hypertonic saline (follow your local protocals). This condition is almost never seen in adults, going to prove that kids are not just little adults.

As for the bicarb, NEVER give it to a kid in DKA. It has been shown to cause a 4 fold increase in the rate of cerebral edema. It also will lead to severe hypokalemia and worsening cerebral acidosis. The key is to fix the underlying problems, namely the lack of insulin and the dehydration. You end point will be when you have removed all of the ketoacidosis, reguardless of the sugar.

This case was not based on a real pt, but it is a good learning experience. Despite his attempts to euthanize this girl, your expert skills saved her and she is released from the hospital a few days later. There is a huge picinc at the ambulance in your honor (Rescue 911 style) and everyone in the girls family hugs you multiple times. Your partner ends up as a chief in the fire department.

[AnthonyM83]

Okay, I'll throw down the next pimp question here (tag team!).

Haha.

As a side note...anyone have that 1989 article on the art of medical pimping?

[spenac]

Despite his attempts to euthanize this girl, your expert skills saved her and she is released from the hospital a few days later. There is a huge picinc at the ambulance in your honor (Rescue 911 style) and everyone in the girls family hugs you multiple times. Your partner ends up as a chief in the fire department.

Good one Doc.