tag:blogger.com,1999:blog-4505990433916682663.post2882227214996114792..comments2024-03-13T02:04:31.476-04:00Comments on Paramedicine 101: Sick KidAdam Thompson, EMT-Phttp://www.blogger.com/profile/18107359165856983910noreply@blogger.comBlogger14125tag:blogger.com,1999:blog-4505990433916682663.post-31428609288121249312009-09-28T18:05:10.510-04:002009-09-28T18:05:10.510-04:00I have not abandoned anyone here, but we just went...I have not abandoned anyone here, but we just went through the G20 summit here and everyone went overboard in preparations. With that and school, I got a little behind in everything.Shaggyhttps://www.blogger.com/profile/10687847155700323439noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-57729116236426460712009-09-18T00:47:47.323-04:002009-09-18T00:47:47.323-04:00Nothing gets past you damned Aussies! I will post ...Nothing gets past you damned Aussies! I will post the second part tomorrow. I think everyone is on the right track.<br /><br />By the way, at the hospital I work at, the ED attending called the resident and I to come in to a patient's room and challenged us to make a diagnosis within 10 seconds. The resident blurted out DKA! after just 3 seconds? Seeing I was perplexed, the resident, asked, "You can't smell the acetone?" I shook my head, no. I didn't. The attending looked at me and just said, "Don't feel bad, not everyone has the gene to smell it." So again, RM is right. *sigh*<br />At least for the most part. :)Shaggyhttps://www.blogger.com/profile/10687847155700323439noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-43221121559667053662009-09-17T18:56:07.111-04:002009-09-17T18:56:07.111-04:00ahhh the old Kussmal's respirations.ahhh the old Kussmal's respirations.Adam Thompson, EMT-Phttps://www.blogger.com/profile/18107359165856983910noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-84905130308204998742009-09-17T18:41:35.118-04:002009-09-17T18:41:35.118-04:00And as an afterthought, ETCO2 would typically be l...And as an afterthought, ETCO2 would typically be low in the high teens and 20s. There are a couple of studies out that show that an low ETCO2 along with clinical correlation can accurately predict a patient in DKA versus just hyperglycemic.medic1488https://www.blogger.com/profile/17355058662904757173noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-72762022602857962262009-09-17T18:21:18.722-04:002009-09-17T18:21:18.722-04:00Huffing came to mind initially but after the full ...Huffing came to mind initially but after the full presentation I'd be getting a BGL to see if hes hyperglycemic.<br /><br />My rationale:<br />1. Acetone smell of DKA is supposedly classic, I've smelt it a couple of times but seen plenty that havent.<br /><br />2. Deep/relatively rapid respirations that would probably be him creating a respiratory alkalosis to (blowing off CO2) to try to help balance his pH which will be low due to metabolic acidosis.<br /><br />3. History of vague illness with nausea and vomiting. Also, although it is not a definite, he lives in close quaters with a brother. If he was vomiting due to something infectious I would expect the brother to be getting ill also.<br /><br />So besides BGL, I would also want an ETCO2, ECG, temp, and further history including recent fluid intake, weight loss, and urinary habits.medic1488https://www.blogger.com/profile/17355058662904757173noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-419191617093237842009-09-17T17:31:30.601-04:002009-09-17T17:31:30.601-04:00From the UK, and only trained in BLS, I'd have...From the UK, and only trained in BLS, I'd have DKA in my differential diagnosis, but also consider that someone may have been doing their nails in the room (I'm not allowed to measure BGL). Child doesn't appear to be big sick, so would probably run him in myslef, under normal road conditions.<br /><br />I'd consider taking him to the ambo in the chair/carried, depending on how much the borderline hypotension is affecting him, and how big he isAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-8929557526364530432009-09-17T14:53:08.237-04:002009-09-17T14:53:08.237-04:00I would be less concerned about identifying this a...I would be less concerned about identifying this as DKA. The smell of nail polish is something that I am able to notice, but I have never noticed it with DKA. OTOH, I have noticed it with the chemicals used for inhalant abuse (huffing).<br /><br />Either way, it is something to ask the mother about. The gene for noticing the ketone smell is apparently not a common one. I was at a conference, where Dr. Mikel Rothenberg was speaking. He asked the audience, "How many of you have smelled this with DKA patients?" Out of a couple hundred people, only about 5 raised their hands. While this should be something to alert us to the possibility of DKA, we should <b>not</b> expect it to be present. Pink frothy sputum is a similarly rare symptom. I have treated hundreds of CHF patients, but only a few have had pink frothy sputum. OTOH, these do make for easy test questions, so instructors love these assessment findings that are the zebras, or even unicorns, of assessment.<br /><br />If there is a pediatric protocol for hypotension, that might be one way to go with a fluid challenge. He states that he is not keeping anything down, so dehydration is expected. As long as his lungs are clear, a fluid challenge seems like a good idea. <br /><br />If this does not fall under one of your protocols, call medical command for permissions to give fluids to an apparently dehydrated vomiting borderline hypotensive child. How many will say no?<br /><br />If he has DKA, there is not much we can do about it. If he does not, then we should avoid focusing on DKA and consider the other possibilities.<br /><br />Unless this is a <b>very</b> big kid, I would carry him, but I'm a big kid, myself. I carry a lot of patients. I would probably put a mask on the kid and wrap him in a sheet, in case he has something infectious. Not ideal, but nothing about EMS is.<br /><br />HR is not unusual, but respirations are. The reverse would be expected for pure dehydration due to vomiting, but blowing off CO2 would explain the tachypnea. A little oxygen by cannula might help in figuring this out. If the respirations slow down and the sat remains the same, or even comes up, then he may have been compensating for a lack of oxygen, rather than an excess of CO2.<br /><br />If he is a hard stick, and dehydrated patients often are, I would not use any kind of IO, unless he suddenly looks a lot worse.Rogue Medichttps://www.blogger.com/profile/07598646309630074992noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-53934369998409929242009-09-17T11:42:05.811-04:002009-09-17T11:42:05.811-04:00akroeze.
What type of reading would you expect ...akroeze. <br /><br />What type of reading would you expect for ETCO2?Adam Thompson, EMT-Phttps://www.blogger.com/profile/18107359165856983910noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-42964823970528742262009-09-17T11:29:50.837-04:002009-09-17T11:29:50.837-04:00Forgot to mention too, our model of glucometer let...Forgot to mention too, our model of glucometer lets us check for ketones in the blood, although we don't carry the strips. Some place might and that would go even further towards DKA if they were present.akroezehttps://www.blogger.com/profile/08672077465468282006noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-2692866056597999042009-09-17T11:28:47.254-04:002009-09-17T11:28:47.254-04:00I agree with high blood sugar being a distinct pos...I agree with high blood sugar being a distinct possibility. Abdominal tenderness would additionally increase suspicion of DKA. ETCO2 may be beneficial in assessment.<br /><br />A cautious 10cc/kg infusion of NS wouldn't be unreasonable here. Don't want to go too agressive on the fluids here lest we cause encephalopathy.akroezehttps://www.blogger.com/profile/08672077465468282006noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-79603483670754154252009-09-17T10:23:01.672-04:002009-09-17T10:23:01.672-04:00Possible, would explain the smell.Possible, would explain the smell.Adam Thompson, EMT-Phttps://www.blogger.com/profile/18107359165856983910noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-63172653034448711572009-09-17T08:23:43.043-04:002009-09-17T08:23:43.043-04:00I'm thinking that it's a first presentatio...I'm thinking that it's a first presentation of type one diabetes, hence high BSLAdamnoreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-87266189091067751002009-09-17T07:55:26.124-04:002009-09-17T07:55:26.124-04:00Nice post Shaggy.
I'd investigate that smell....Nice post Shaggy.<br /><br />I'd investigate that smell. Treat for possible dehydration. I actually feel the sugar would probably read low with the Hx of vomiting. From the American Adam's prospective.Adam Thompson, EMT-Phttps://www.blogger.com/profile/18107359165856983910noreply@blogger.comtag:blogger.com,1999:blog-4505990433916682663.post-32222211331637595062009-09-17T06:33:05.968-04:002009-09-17T06:33:05.968-04:00I'd grab a blood sugar level reading. Based o...I'd grab a blood sugar level reading. Based on your history, I'd think it is going to be high. My guidelines don't allow me to initiate iv fluid for hyperglycemia kids (only adults), but an intensive care paramedic is able to, so I'd be calling for them. Pt needs to go to hospital. Maybe carry him to the ambulance, he's only young. <br /><br />That's from an Australian perspective.Adamnoreply@blogger.com