9. History Abdominal pain X 2 days associated with vomiting 5 times /day , small to moderate amount , non projectile , Loose motion 5 times /day , small amount semisolid , no blood or mucous Child is less active , not feeding well h/o cough and cold during the last week and now improved No h/o fever No past h/o medical problem
10. 2 survey O/E : Small boy , looks unwell, tachypnic , but alert and responding Not jaundiced or pale Dry mucous membrane Capillary refilling 3 sec ears : clear Throat : mild congestion and mild enlarged tonsils Chest ….. Clear CVS …… S1+S2, no gallop, no murmur Abdomen: soft with ?epigastric tenderness, BS +ve, no hepto-splenomegaly CNS :no neurologic deficit, no meningeal signs .
11. What is your impression? What is your next step ?
12. Impression : gastroenteritis with moderate dehydration ( 5-7%) Plan : Blood investigations: cbc, ue1 IVF 20 ml /kg NS bolus , then dextrose saline 0.45 % @100 ml/hr + kcl 10 mmol/500 ml To give ondasterone and try oral intake Reassess later
13. Reassessment After 1 hour : The child looks unwell Not active , but still alert and responding RR 37 Capillary refilling 3 sec The mother said he is drinking good amount of water but he vomited 3 times and had one small amount of loose stool.
15. It was the end of the shift The case handed over to the next coming team After reassessment , they sent VBG and showed pH of 7.2 and they check reflow it was 16 mmol/l So it was DKA and they started management
17. DKA is the leading cause of morbidity and mortality in children with T1DM ranging from 0.15 % to 0.31 % . In addition, DKA also can occur in children with T 2 DM; this presentation is most common among youth of African-American descent.
18. DEFINITION Consensus statements from the European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society in 2004, the American Diabetes Association in 2006, and the International Society for Pediatric and Adolescent Diabetes in 2007 defined the following biochemical criteria for the diagnosis of DKA : 1-Hyperglycemia, defined as a blood glucose of >200 mg/dL (11 mmol/L) AND 2-Metabolic acidosis, defined as a venous pH <7.3 and/or 3-a plasma bicarbonate <15 meq/L (15 mmol/L)
19.
20.
21.
22.
23. Take home messages 1-Not every loose motion and vomiting is a GE. 2-If a dehydrated child not responded to fluid therapy , and it is unlikely to be sepsis , ask yourself : is it a DKA ? 3-check reflow for pt with ketone positive in the urine .
