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Pediatric Trauma

Melanie Munns, MSN, RN, CEN, CFRN

Objectives

• At the conclusion of this presentation, the learner will be able to:

• Describe the anatomical differences of children and adults

• Describe common injury patterns in children

• Discuss the emergency medical treatment of various traumatic injuries in the pediatric population

What Makes Kids Scary?

• Is it their size?

• Is it their differences?

• Is it their vulnerability?

• How do we address these in our practice?

• How do we approach a little kid?

• How about one that’s broken?

• We all approach patient care from our own perspective

• We all treat each patient a little differently

What Makes Kids Special?

• Is it their size?

• Is it their differences?

• Is it their vulnerability?

• Is it their potential?

• Children are remarkably resilient

What Makes Kids Different?

• Anatomically

• Developmentally

• Medically

Anatomical Differences

• Thermoregulation

• Airway

• Head

• Neck/Spine

• Chest

• Cardiovascular

• Abdomen/Liver

• Extremities/Bones

• Skin/Subcutaneous

Metabolism and Thermoregulation

• Higher metabolic rates thus higher demands

• Under-developed hypothalamus

• Less insulation

• Fewer glycogen stores

– More easily depleted

Airway

• Almost everything is smaller

• Tracheal rings not fully developed

• Larger tongue

• Fewer alveoli

• Larger occiput

https://www.pedilung.com/pediatric-lung-diseases-disorders/anatomy-of-a-childs-lung/

Head

• Proportionately larger and heavier heads

• Cranium is thinner and more pliable

• Higher percentage of water

• Neurons are not yet myelinated

• Open fontaneles

• Larger head causes more force to be applied to cervical spine during high-energy events

• Weaker neck muscles

• Ligament laxity

• Wedge-shaped vertebral bodies

• Immature facets of spine

• Spinal elasticity

Spine

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 23624

Chest

• Thinner chest wall

• Cartilaginous and horizontal ribs

• Underdeveloped intercostal muscles

• Flatter diaphragm

• Mechanics of ventilation

• More susceptible to diaphragmatic displacement

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 8090

Adult

Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 46487

Pediatric

Cardiovascular

• Proportionately higher blood volume

– 80-100 mL/kg

• Higher oxygen consumption

• Less compliant myocardium

• Cardiac output primarily driven by heart rate

• Sensitive to parasympathetic stimulation

Abdominal

• Thin abdominal walls

• Protuberant abdomen

• Relatively large liver

• Flexible ribs offer little protection

• Intestines not completely attached

• Kidneys more mobile

Bones and Skin

• Bones are not fully ossified

• Flexible, more prone to incomplete fractures

• Epiphysis

• Skin is thinner

• Brown fat v. white fat

Medical Differences

• Medications

• Treatments

• Weight based

Medications

• TXA?

• Zofran?

• Ketorolac?

• Emergency medications

• Pain control

• Because of their higher metabolic rate, pediatric patients tend to burn through medications faster

– Pain medications

– Paralytics

Treatments

• Spinal precautions?

• Intubation?

• Traction splints?

Weight Based

• Most medication dosages are weight based

• Some treatments are weight based

• Accurate body weight

• Ideal body weight

• Calculation formulas

• How do you get it?

Weight—What?

• ALWAYS in Kg

• Calculation

– Weight = 3(age)+7

• Best Guestimates

• Length-based resuscitation tape (LBT)

• Which is better?– “Ideal body weight (IBW) estimates may be a better indicator of Vd for

hydrophilic drugs, as they correlate better with lean body mass….The main drugs used in paediatric resuscitation are hydrophilic” (Carasco, Fletcher & Maconochie, 2016)

Injury Patterns

• Incidence by mechanism

“Sports and recreation activities were also the most frequently reported cause of injury-related ED visits among pediatric patients, representing approximately 1 in 5 injury-related ED visits among patients aged 19 and under” (Scheu, Chen & Hedegaard 2016)

• Incidence of injury

– Sports and recreation:• Males

• 5-24 years old

• Caucasian

Non-Fatal Injuries

Causes of Death

What’s New?

• Tranexamic acid (TXA)

• Spinal precautions

• Surgical interventions

• Resuscitative endovascular balloon occlusion of the Aorta (REBOA)

Tranexamic Acid - TXA

• A fibrinolytic inhibitor

• Safe for use on pediatrics 2 years or greater

• Best efficacy within three hours of injury

• Harmful if given more than six hours post-injury

• Indications:

– Known or suspected traumatic hemorrhage

– Signs of poor perfusion

https://www.gettyimages.com/detail/photo/red-blood-cell-fibrin-sem-high-res-stock-

photography/155301464

Spinal Imaging

• Incidence of cervical spine injury = <1%

• CT Scan = 100 to 500 times more radiation than X-Rays (McMahon, et al., 2015)

• CT Scan = Higher incidence of solid cancer

– Especially important for c-spne CT as the Thyroid is highly sensitive to radiation

• CT more likely to miss cervical injury than MRI

Spinal Precautions

One clinical clearance protocol in Baton Rouge

• Glasow Coma Score (GCS) of 15

• No neck pain

• No neurological deficit

• No intoxication

• No distracting injuries

• Ability to communicate at a developmentally appropriate level

• Clinically cleared 35% more pediatrics

(McMahon et al 2015)

Resuscitative Endovascular Balloon Occlusion of the Aorta REBOA

• Used in catastrophic injuries to chest, abdomen or pelvis

• Similar survival rates in pediatric patients compared to adults

(Norii et al 2017)

https://www.aliem.com/wp-content/uploads/2017/07/Pelvic-Trauma-REBOA.jpg

Specific Injuries and Treatments

• Traumatic Brain Injury

• Spinal Trauma

• Chest Trauma

• Abdominal Trauma

• Musculoskeletal Trauma

Traumatic Brain Injury (TBI)

• Head injury is the most common cause of death

• Infants

– Fontanelles are open until 18 months

– Scalp lacerations can cause significant hemodynamic compromise

• PECARN Head Trauma Study

– Limits the exposure to radiation

– Did not CT scan more than 50% of the specific population

(Morrisey & Fairbrother, 2015)

PECARN Criteria

Younger than 2

years old

2 years and

older

Traumatic Brain Injury

• The injury formerly known as concussion

• No longer graded for severity

• Symptoms:

– Thinking and remembering

– Physical

– Emotional / Mood

– Sleep

https://tapintoteenminds.com/beauty-elementary-mathematics/oame-ignite-the-beauty-

of-elementary-mathematics-17-symbolic-notation-prince-symbol/

https://tapintoteenminds.com/beauty-elementary-mathematics/oame-ignite-the-beauty-of-elementary-mathematics-17-symbolic-notation-prince-symbol/

Second Impact Syndrome (SIS)

• Occurs with a second TBI before resolution of initial TBI

• Failure to autoregulate arteriole diameter

• Increases cerebral blood blow

• Massive cerebral edema or “hyperemic herniation”

• Decreased cerebral perfusion pressure

• Herniation

• Mortality may be as high as 50%

• Morbidity (aka: disability) is 100%

By OpenStax - https://cnx.org/contents/[email protected]:fEI3C8Ot@10/Preface,

CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=30147959

Intracranial Hemorrhage

• Epidural

– Between the skull and the dura mater

– HA, N/V, Sz, LOC

• Subdural

– Between dura and arachnoid

– More common under 2 y/o

– Irritability, N/V, decreased LOC (lethargy/coma)

– Sz

https://step2.medbullets.com/neurology/120299/epidural-hematoma

Intracranial Hemorrhage

• Subarachnoid

– Between arachnoid and pia mater

– Uncommon in children, usually associated with vertex or basilar skull fractures

– HA, N/V, nuchal rigidity, fever

• Intercerebral

– Bleeding into brain tissue

– HA, N/V, progressive LOC

– Unequal pupils, confusion

https://www.pedsradiology.com/Historyanswer.aspx?qid=551&fid=1

• Most commonly caused by MVC

• Rotational or acceleration-deceleration injuries

• Shearing of axons

• Multifocal petechial bleeding

• Disruption of neural impulses

• Instantaneous loss of consciousness

• >90% remain in a persistent vegetative state

Diffuse Axonal Injury

https://emedicine.medscape.com/article/339912-overview#a4

Spinal Trauma

Spinal Trauma

• Higher C-Spine injury more likely in <8 y/o

• Chance fractures common

• SCIWORA

Find the Injury

Spinal Cord Injury (SCI)

• Contusion

• Concussion

• Laceration

• Complete

• Incomplete

Spinal Cord Injury (SCI)

By Polarlys and Mikael Häggström - File:Medulla spinalis - tracts - English.svg by

Polarlys (translation by Selket)., CC BY-SA 3.0,

https://commons.wikimedia.org/w/index.php?curid=10909281

Anterior

Posterior

Incomplete Spinal Cord Injury

• Anterior cord – crude sensation intact, no motor

• Central cord – loss of fine motor in arms/hands

• Brown-Sequard

– motor and sensation lost on ipsalateral side

– Pain and temperature are lost on contralateral side

• Posterior cord – loss of proprioception

• Cauda equina rare in pediatrics

Spinal v. Neurogenic Shock

• Spinal Shock is nervous

– Transient loss of function

– Flaccid paralysis

– Loss of spinal reflexes

– Loss of pain, proprioception, temp sensation below

– Hyperesthesia above

• Neuorgenic shock is vascular

– Damage to the spinal cord above T6

– Unopposed parasympathetic stimulation

– Distributive shock

Spinal v. Neurogenic Shock

• Spinal Shock is nervous

– Treatment is supportive

• Neuorgenic shock is vascular

– Treatment • Promote vasoconstriction

• Increase heart rate

• Cautious fluid administration

Chest Trauma

• Rib fractures

• Pulmonary contusions

• Pneumothorax

• Hemothorax

– May lose up to 40% of blood volume

• Tension pneumothorax

– Increased intrathoracic pressure

Cardiac Trauma

• Blunt Cardiac Injury (BCI)

– Less than 5% of pediatric blunt chest trauma cases

– Dysrhythmias

– Heart failure

– Rib fractures

• Cardiac Tamponade

– Muffled heart tones, JVD, hypotension (Beck’s triad)

– Pulsus Paradoxus

• Commotio Cordis

– Blow to the chest during the refractory period

– 42 to 85% mortality rate

https://emedicine.medscape.com/article/104363-overview#a2

Abdominal Trauma

• Third most common cause of traumatic death

• Easily missed and can be fatal

• Look for the Seatbelt Sign or Handlebar mark

• May have elevated AST/ALT

– Highly predictive in presence of positive physical exam

– Not specific to any particular organ

• Amylase/Lipase do not appear to be diagnostic

• Serial Hemoglobin/Hematocrit in hemodynamicallystable patients

Focused Assessment Sonography for Trauma

https://www.slideshare.net/ypuckett/pediatric-abdominal-trauma

Liver & Spleen Injury

• Graded (I-V) by degree of damage

– Subcapsular hematoma

– Laceration

– Vascular

• If hemodynamicaly stable, treating non-operatively

– Effective in 90-95&% of pediatric cases

• Angioembolization less useful in pediatrics

Pancreatic Injury

• Less than 5% of pediatric abdominal injuries

• Epigastric pain and bilious emesis

• Elevated amylase and lipase, but does not coincide with outcome

• Usually non-surgical

• Bowel rest

Renal Injury

• Graded similar to liver and spleen

• Most severe grade injuries are related to off-road motorcycles, ATV rollovers and bicycles

• Flank pain or bruising

• Posterior rib fractures

• Typically presents with hematuria

• Conservative management except in hemodynamic instability

• Angioembolization effective in most hemorrhagic cases

https://www.slideshare.net/ypuckett/pediatric-abdominal-trauma

Musculoskeletal Trauma

• 30% to 45% of pediatric traumatic injuries

• Mostly similar to adults

• Buckle fractures

– Axial loading

• Greenstick

– Common in clavicle or arm

• Epiphyseal-metaphyseal

– Fractures through the growth plate

Buckle Fracture

Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 23950

Greenstick Fractures

Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 21674

Salter-Harris Fractures

Case courtesy of Dr Gagandeep

Singh, Radiopaedia.org, rID: 8476

Case courtesy of Dr Matt Skalski,

Radiopaedia.org, rID: 27144

Summary

• Pediatrics are not just small adults

• Anatomy, physiology and response to injury is different

• Our approach and treatments have to be adjusted accordingly

• As healthcare providers, we have an extra responsibility to this vulnerable population

Contact

Always happy to hear from you

[email protected]

References• Carasco, C.F., Fletcher, P., & Maconochie, I. (2016) Review of commonly used

age-based weight estimates for paediatric drug dosing in relation to the

pharmacokinetic properties of resuscitation drugs. British Journal of Clinical

Pharmacology 81(5), 849-56. DOI: 10.1111/bcp.12876

• Center for Disease Control and Prevention. (2018, June 22). CDC’s

Developmental Milestones. Retrieved from

https://www.cdc.gov/ncbddd/actearly/milestones/index.html

• Center for Disease Control and Prevention. (2019, Feb 7). Ten Leading Causes

of Death and Injury. Retrieved from

https://www.cdc.gov/injury/wisqars/LeadingCauses.html

• Chrisman, S.P., Lowry, S., Herring, S.A., Kroshus, E., Hoopes, T.R., Higgins,

S.K., & Rivara F.P. (2018, Dec 13). Concussion incidence, duration, and return

to school and sport in 5- to 14-year-old American football athletes. Journal of

Pediatrics. DOI: https://doi.org/10.1016/j.jpeds.2018.11.003

• Haarbauer-Krupa, J., Arbogast,K., Metzger, K., Greenspan, A., Kessler, R., Curry, A., Bell,J., DePadilla, L., Pfeiffer, M., Zonfrillo, M., & Master, C. (2018, Apr 4). Variations in Mechanisms of Injury for Children with Concussion. Journal of Pediatrics.

References 2

• Hashikaw,a A., Juhn, Y., Homme, J., Gardner, B., & Moore, B. (2007, Dec). Does length-based resuscitation tape accurately place pediatric patients into appropriate color-coded zones? Pediatric Emergency Care. 23(12):856-61. DOI: https://doi.org/10.1016/j.jpeds.2018.01.075

• Luscombe, M.D., Owens, B.D., & Burke, D. (2011, Jul). Weight estimation in paediatrics: a comparison of the APLS formula and the formula 'Weight=3(age)+7' EmergencyMedical Journal 28(7):590-3. DOI: 10.1136/emj.2009.087288. Epub 2010 Jul 20.

• McMahon, P., Alwood, S., Zeretzke-Bien, C., Chalasani, S., Herskovitz, S., Blanchard, M., & Lin., Y.P. (2015, Sept-Oct). Protocol to Clear Cervical Spine Injuries in Pediatric Trauma Patients. Radiology Management (37:5). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26571972

• Morrisey, D., Fairbrother, H.E. (2015, February 14) Pediatric trauma: Pearls and pitfalls. emDocs. Retrieved from http://www.emdocs.net/pediatric-trauma-pearls-pitfalls/

References 3

• Norii, T., Miyata, S., Terasaka, Y., Guliani, S., Lu, S.W., & Crandall, C. (2017 May).Resuscitative endovascular balloon occlusion of the aorta in trauma patients in youth.Journal of Trauma and Acute Care Surgery.;82(5):915-920. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28030495

• Pang, D. (2004, Dec). Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery (55:1325-43). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/15574214

• Pucket, Y. (2014, October 21). Pediatric abdominal trauma. Retrieved from https://www.slideshare.net/ypuckett/pediatric-abdominal-trauma

• Scheu, Y., Chen, L., & Hedegaard, H. (2016, Nov 18). Sports- and recreation-relatedinjury episodes in the United States, 2011–2014. National Health Statistics Reports (99).

• Weinstein, E., Turner, M., Kuzma, B.B., & Feuer, H. (2013). Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Journal of Neurosurgery: Pediatrics PED, 11(3), 331-334. Retrieved from https://thejns.org/view/journals/j-neurosurg-pediatr/11/3/article-p331.xml

WHEN THE PLUMBING IS NOT RIGHT: PEDIATRIC SURGICAL EMERGENCIESGARRET ZALLEN MD, FACS

I HAVE NOTHING TO DECLARE

EXCEPT I AM NOT A PLUMBER

GOALS:

• Discuss common pediatric surgical emergencies that have

implications affecting their safe stabilization and transport

• Learn about the physiologic consequences of these congenital

anomalies

• Provide an understanding of how to safely manage these

babies

CONGENITAL PLUMBING MISTAKES

• Esophageal Atresia with Tracheo-esophageal fistula

• Duodenal Atresia

• Malrotation with Volvulus

• Imperforate Anus

• Gastroschisis

• Congenital Lobar Inflation

EA WITH TEF

• First described in 1600’s

• First operative attempt to repair EA in 1888; first successful

primary repair 1941

• Incidence varies widely- in USA 1 in 4500

• Male to female ratio 1: 1.26

EA WITH TEF

EA WITH TEF- CLUES TO DIAGNOSIS

• Prenatal ultrasound may show polyhydramnios

• Excessive drooling

• Aspiration of feedings

• choking

• coughing

• cyanosis

• Inability to pass an oro/nasogastric tube


• Respiratory distress-

•aspiration from pooled secretions in upper

pouch

• reflux from stomach into tracheobronchial

tree

• tracheomalacia

•gastric distension

EA WITH TEF- DIAGNOSIS

EA WITH TEF- STABILIZATION

• Need to control the secretions:

• Place suction catheter into proximal esophagus

• Give supplemental oxygen as needed

• Place baby on their side to allow secretions to drain from mouth

• IV access and fluids

• Monitor Glucose

EA WITH TEF- STABILIZATION

• Be aware there may be other anomalies affection the baby’s physiology

• Cardiac- get an ECHO if possible

• Renal

• Other gut atresias

• Imperforate anus

EA WITH TEF- TRANSPORTATION

• You are transporting a term infant with EA-TEF, with a normal ECHO and

everything is going well until: The baby starts coughing and choking-

What is happening- what do you do??


• Most likely cause is a clogged esophageal tube- Remove and replace with

new one to same depth


• That worked for a few minutes but now the baby is starting to drop his

saturations- supplemental O2 and suctioning is not working- you notice this


• The baby is so distended that he is having difficulty breathing and you have no

choice but to intubate-

• What are the considerations for intubation and ventilation?

• Strategies for difficulty ventilating:

• Make sure the tube is not to deep and in the fistula

• Gentle pressures- path of least resistance

• Right Main stem intubation

• Focus on adequate oxygenation, not EtCO2

DUODENAL ATRESIA- (OTHER INTESTINAL ATRESIAS)

• Atresias can occur any where in the GI tract

• Duodenal

• Small bowel

• Colon

• Anus

• Duodenal atresia is most common

DUODENAL ATRESIA- DIAGNOSIS

• Emesis after birth- bilious or non-bilious

• Dilated stomach with no distal air

DUODENAL ATRESIA- TRANSPORT

• Main focus is gastric decompression and avoiding aspiration

• Place “real” gastric decompression tube- OG is usually preferable

DUODENAL ATRESIA- TRANSPORT

• You are transporting a DA new born and everything is going well, but the

baby now seems lethargic, pale and diaphoretic- the tube is working well

What is the problem??

MALROTATION WITH VOLVULUS

• What is this?


• How does it present?


• Bilious emesis

• Usually appears at day of life 1-3.

• May occur anytime in a person’s life time

MALROTATION WITH VOLVULUS- TRANSPORT

• Gastric decompression

• IV fluids

• Rapid transport to treating facility- time is bowel and the loss of the

entire midgut is catastrophic

IMPERFORATE ANUS

IMPERFORATE ANUS

• As any parent knows kids can be a**holes- but most people do not know

they can be born without one

• Most distal intestinal obstruction

• There are several different varieties, but common thread is the anal

opening is either not present or too small and in the wrong place

IMPERFORATE ANUS

• Can have abdominal distension late- but need to be aware of other

associated anomalies-

• VACTERL

GASTROSCHISIS

GASTROSCHISIS

• Baby is born with most of intestines herniated through a small hole to the

right of the umbilicus

• Almost all of these are diagnosed prenatally

• Usually the only problem- unlike omphalocele

• Can have normal lives if the bowel is kept safe

GASTROSCHISIS- TRANSPORT

• Major considerations

• Keep the baby warm

• Keep the bowel covered and safe

• Be able to see some of the bowel to look for ischemia

• Gastric decompression

• IV access

GASTROSCHISIS- TRANSPORT

• During transport the bowel begins to look grey and underperfused- was

previously pink- What do you do?

• Reposition the baby/bowel

• Check pulse ox- bowel can be the bellwether

• Fluids- tremendous loss of fluids and will require boluses

CONGENITAL LOBAL OVERINFLATION

CONGENITAL LOBAL OVERINFLATION

• Previously called Congenital Lobar Emphysema

• Lung tissue is normal

• Airway stenosis or floppy- allowing air to enter but not exit

• Depending on the anatomy can vary from requiring no treatment to

being life threatening

CONGENITAL LOBAL OVERINFLATION- TRANSPORT

• Avoid positive pressure ventilation

• Carefully consider mode of transportation- air vs. ground


• You are transporting a baby with a CLO who was intubated and he

begins to deteriorate- poor perfusion, dropping O2 saturations, tracheal

deviation- What do you think is happening?


• You try all these things and nothing is working-

OTHER PLUMBING MISHAPS

• Cardiac- multiple!

• Neurologic- hydrocephalus

• Renal- obstructions

• Vascular- coarctaction, AV fistulas, lymphatic malformations

• Others-

THANK YOU AND ANY QUESTIONS?

DIABETIC EMERGENCIES

Angela Zallen, MD

Pediatric Hospitalist

Peacehealth Medical Group

August 18, 2019

Disclosures

I have no financial disclosures

What is DKA?

Profound insulin deficient state characterized by

hyperglycemia, hyperosmolarity, ketosis, and acidosis

What is DKA?

• Profound insulin deficient state characterized by

hyperglycemia, hyperosmolarity, ketosis, and

acidosis

• Increase in counterregulatory hormones with

increased normal physiologic mechanisms

What is DKA?



Increase in counterregulatory hormones with


Hyperglycemia and accumulation of ketoacids -->

osmotic diuresis with water and electrolyte losses and

metabolic acidosis

What is DKA?



Increase in counterregulatory hormones with


Hyperglycemia and accumulation of ketoacids -->

osmotic diuresis with water and electrolyte losses and

metabolic acidosis

Severe depletion of water and electrolytes from intra

and extracellular compartments

What is the criteria for DKA?

Criteria for DKA

Serum glucose >200 mg/dL

Ketonuria (mod or large) or ketonemia (BOHB >

3mmol/L)

pH <7.3 OR HCO3 < 15

Prevalence

• In 2009, 192,000 children were diagnosed with

diabetes mellitus

• Hospitalizations for DKA have been increasing over

the last 2 decades

• 188,965 DKA admissions in 2014

• 11% of these in children <17 years old

• Mortality has decreased, but DKA is a major cause

of mortality in IDDM

Setting of DKA

• Most common is new onset type 1 diabetes mellitus

(30%), but also type 2 (10%)

• Known type 1 IDDM with inciting factor

• Infection

• Intercurrent illness

• Inadequate insulin administration

Treatment Goals

1. Correct insulin deficiency


2. Reestablish circulating volume then slowly correct dehydration

Treatment Goals

Treatment Goals



3. Reverse ketosis and resolve metabolic acidosis

Treatment Goals




4. Normalize blood glucose levels

Treatment Goals





5. Replenish electrolyte losses

Treatment Goals






6. Identify precipitating events

Treatment Goals







7. Avoid complications

Treatment Goals







7. Avoid complications

8. Prevent further episodes through diabetic education

Mortality in DKA

Ranges from 0.15-0.33% - cerebral edema accounts

for most of these cases

Incidence of cerebral edema is 0.5-0.9%

Mortality in cases of cerebral edema with DKA is 21-

24% with significant morbidity among survivors

Case #1

14 year old previously healthy male comes in to the

ED with vomiting, generalized abdominal pain, and

15 pound weight loss in the last 3 months.

Further history reveals: frequent urination, excessive

thirst, and increased appetite.

POC blood glucose in the ED reads “high”

UA shows large glucose and ketones

VBG shows a pH of 7.0, pCO2 20, and HCO3 of 7

What do you want to know?

PALS

ABCD

Vital signs

Degree of dehydration

Mental status (Glasgow coma scale)

Cushing’s triad present?

Shock?

PALS

Assess airway and breathing before circulation

Assess, ensure, and maintain patency of airway

Assess and monitor integrity of breathing

Apply supplemental O2 for patients with circulatory,

respiratory, or neurologic impairment

What are the signs of respiratory insufficiency?

Respiratory Insufficiency

Hypoxemia and hypoventilation

Slowing of respirations (bradypnea)

Decreased respiratory effort

Decreasing O2 sat or increasing CO2 on

capnography

Signs of respiratory insufficiency should be treated

with what interventions?

Depends on the degree of respiratory insufficiency or

respiratory failure.

Supplemental oxygen

Nasal/Oral Airway

Bag mask ventilation

Intubation and mechanical ventilation

Disability: Assess for neurologic stability

Glasgow Coma Scale

GCS for Kids

Eye opening response

Spontaneous eye opening

Opens to verbal command

Opens to pain, not to face

None

4

3

2

1

Verbal Response

Oriented

Confused conversation

Inappropriate responses

Incomprehensible speech

None

5

4

3

2

1

Motor Response

Obeys command for movement

Purposeful movement to painful stimulus

Withdraws from pain

Abnormal (spastic) flexion - Decorticate posturing

Extensor (rigid) response - Decerebrate posturing

None

6

5

4

3

2

1

GCS for Kids <5

Score 2 to 5 Years 0 to 23 Months

5Appropriate words or

phrases

Smiles or coos

appropriately

4 Inappropriate words Cries and consolable

3Persistent cries and/or

screams

Persistent inconsolable

crying/screaming

2 GruntsGrunts, agitated, or

restless

1 No response No response

Presenting Symptoms of DKA

• Dehydration: poor skin turgor, delayed cap refill

• Usually maintain blood pressure unless overt hypovolemic

shock

• Abdominal pain: ileus, can mimic acute abdomen in

early DKA

• Potassium depletion, acidosis, poor splanchnic perfusion

• Kussmaul respirations: rapid deep respirations

• Attempt to decrease pCO2 and compensate for metabolic

acidosis

Back to our Case

Vital signs:

HR 140, RR 40, BP 89/56, O2 sat 96% on room

air

Kussmaul respirations

Acetone smell on his breath

What else are you looking for?

Neurologic exam:

Mental status: tired appearing, oriented to person

and place, responsive to voice, responds to painful

stimulation verbally, follows commands

Cranial nerve exam: pupils equal, round and

reactive to light. Extraocular movement intact.

What do you do first?

Get Access!!

Place 2 peripheral IV lines to assure adequate

access

If impossible to place peripheral IVs due to

dehydration, place IOs. You can infuse anything into

an IO that you can infuse into an IV.

Then What?

a. 10 ml/kg Sodium bicarbonate infusion

b. Insulin bolus of 10 units

c. 10 ml/kg NS bolus over 1 hour

d. 20 ml/kg NS bolus wide open

ANSWER

c. 10 ml/kg NS bolus over 1 hour

Start fluid resuscitation slowly as this will effectively

drop his serum glucose and should be done gradually

to prevent cerebral edema.

Do not give > 40 ml/kg during initial fluid resuscitation

Fluid resuscitation should be started prior to starting

insulin therapy

Overt Hypovolemic Shock

• Marked tachycardia, absent peripheral pulses, weak

central pulses, cool extremities, prolonged capillary

refill, narrowing pulse pressure, AMS, hypotension

• Infuse 20 ml/kg normal saline through large bore

peripheral IV

• Needs PICU consultation

• Reassess neurologic status, GCS, physical exam

after each bolus

• Monitor glucose closely, may need dextrose infusion

to prevent rapid drop in glucose concentration

Why not choice b, an insulin bolus?

Drops serum glucose too quickly and may increase

risk of cerebral edema and worsen hypokalemia

Insulin drip should be initiated 1-2 hours after starting

fluid replacement at a rate of 0.05-0.1 units/kg/hour

Why not choice a, infusion of sodium bicarbonate?

Sodium Bicarb in DKA

Sodium bicarbonate has been shown to initially improve

acidosis in the first 2 hours of DKA therapy

No benefit after the first 2 hours

Increased tissue hypoxia

May interfere with tissue oxidation and renal excretion of

ketones = worsens ketosis (weak evidence)

Increased risk of cerebral edema and prolonged

hospitalization

CASE #1.5

Take the same kid as above:

14 year old previously healthy male who presents to

the ED with a 24 hour history of vomiting, abdominal

pain, and 15 pound weight loss over 3 months.

CBG in the ED reads “high”

UA shows large glucose and ketones

VBG shows a pH of 7.0, pCO2 20, and HCO3 of 7

Vital signs:

HR 140, RR 35, BP 94/60, O2 sat 96% on room

air

Kussmaul respirations

Acetone smell on his breath

You initially examine him and he is alert and oriented,

conversing, but tired appearing. Responsive to voice

commands.

He arrives on the floor and he appears listless,

obtunded and with a dilated right pupil that is not

reactive to light. He responds to painful stimulation

with flexion of his arms and extension of his legs.

What happened??

Cerebral Edema

1 diagnostic criterion, 2 major criteria, or 1 major + 2

minor criteria

Cerebral Edema

Diagnostic Major Minor

Abnormal motor or verbal response

to pain

Altered or fluctuating level of

consciousnessVomiting

Decorticate or decerebrate

posturing

Sustained heart rate deceleration

not attributable to intravascular

volume repletion or sleep state

Headache

Cranial nerve palsy Age inappropriate incontinence Lethargy

Abnormal respiratory pattern Diastolic BP >90

Age <5 years

What Causes Cerebral Edema?

• Incompletely understood

• Newer studies suggest that it is not related to rate of

fluid infusion

• Likely multifactorial – newer theories include:

• Cerebral hypoperfusion with reperfusion injury

• Neuroinflammation

• Vasogenic edema

• Increased permeability of blood brain barrier

What do you do about it?

Requires PICU admission

....but you have at least 2 hours to wait.....

Cerebral Edema Management

Look for early warning signs of cerebral edema i.e. do frequent

neuro checks



neuro checks

Mannitol: 0.5-1 g/kg over 10-15 minutes, repeat in 0.5-2 hours

Osmotic diuresis and decreases blood viscosity --> improves cerebral

perfusion and O2 delivery



neuro checks




3% Hypertonic saline: 2.5-5 ml/kg over 10-15 minutes

Prevents hyponatremia and hypovolemia, improves blood viscosity -->

improves cerebral perfusion



neuro checks




3% Hypertonic saline: 2.5-5 ml/kg over 10-15 minutes

Prevents hyponatremia and hypovolemia, improves blood viscosity -->

improves cerebral perfusion

Intubation and hyperventilation: Indicated to protect the airway of

comatose patients, provide ventilation for apneic patients.

Who is at highest risk of cerebral edema?

i.e. Who needs immediate ICU admission?

Children < 5 years of age

Developmental delay or conditions impairing communication

GCS <13 after fluid resuscitation

Abnormal neuro exam after fluid resuscitation

Other organ system dysfunction

Severe acidosis - presenting pH <7.15, presenting HCO3 <5

Severe hypocapnia: presenting pCO2 <10

Elevated Blood Urea Nitrogen: presenting BUN >30

If patient received IV bicarb or insulin bolus

Calculated mOsm >350

Patient received > 40 ml/kg total initial volume replacement

Corrected Na <140 or decreasing with subsequent labs

Corrected Na = measured Na + [(serum glucose - 100) / 100 x

1.6]

Role of Neuroimaging

• Head CT can be used for radiologic evidence of

cerebral edema

• Brain MRI can be useful to evaluate for cerebral

edema in the setting of acute alteration in mental

status

• Looking for ischemic stroke, dural venous sinus

thrombosis, other neurologic injuries

References

Seattle Children’s Hospital DKA pathway, Guideline and Implementation

Tools. Revised 04/2014.

Chua, H.R.; Schneider, A.; Bellomo, R. Bicarbonate in Diabetic

Ketoacidosis - a systematic review. Ann Intensive Care 2011; 1: 1-12.

PALS provider manual

Levin, D. Cerebral Edema in Diabetic Ketoacidosis. Pediatric Critical Care

Medicine 2008; 9: 320-329.

Cashen, K; Peterson, T. Diabetic Ketoacidosis. Pediatrics in Review August

2019; VOLUME 40, ISSUE 8

Raghuropathy, P. Diabetic Ketoacidosis in Children. Indian Journal of

Endocrinology and Metabolism; 2015 Apr; 19(suppl 1): S55-S57

Thank you!

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