My goal with this 3 part post is to discuss a particular disease state focusing on the pathophysiology and the current treatment guidelines and their rationale. Let's start with the presentation:
Introduction
You are the medic working with with an EMT on a 12 hour shift in an urban low income, mixed race neighborhood. You have been running non-stop for 9 hours, doing two BLS and 5 ALS trips, and you are hungry, tired, and have 4 PCRs to type up yet (while your partner only has two). It is a typical cold winter day with snow flurries. The heater is on to not only warm you guys but as a half hearted attempt to keep your food warm that is sitting on the dash over the defroster duct. You have been nibbling at your sandwich over the past couple of hours. Just as you take a bite, you get a call for a 9 YOM "sick and vomiting". Your partner slams her hand on the steering wheel while you yell out a few expletives. "This kid better be sick!" Your partner yells out, "Who calls an ambulance for vomiting?" Why ask? We get these calls everyday, and will continue for a long time.
You pull up to an old row house in this old mill town and see a somewhat neat front porch atop a flight of stairs with bikes in the front yard. You are already thinking you aren't carrying someone down these stairs for just feeling sick. This kid is going to walk. You grab the clipboard while your partner grabs the jumpbag and you ascend the stairs to the house. The door opens and an overweight but neat appearing woman in her late 20s opens the storm door. She appears concerned and tells you it is her son who is sick. She holds the door open as you and your partner pass through. She tells you he is upstairs in bed and scurries past you to lead the way to his room. Great. More steps. This kid is definitely walking.
Chief Complaint
As you climb the stairs, you try to illicit a history of present illness. She tells you he has been sick the past few days, progressively getting worse. "So why now are you calling?" You ask. She turns around to see the expression on your face as she senses a slight sarcasm in your voice. You quickly add, "I mean, what prompted you to call now? What is worse this evening?"
"He has been throwing up all day and now and is weak, laying in bed all day," she says as she turns the corner and heads down the hall. "He won't even play his video games."
"Has he had a recent fever?", you ask. She tells you she didn't notice and does not have a functioning thermometer. "Do you think it is the flu?" she asks. You shrug your shoulders. You ask about his medical history. He has none other than a T&A (tonsillectomy/Adenoidectomy) done last year.
Your partner asks, "Did you call your PCP for guidance?" and the woman answers that she thought she should just take her child to the ER. Yeah, the ER-the abused modern day clinic. Your partner asks if she has a car to drive him to the hospital and the woman says no. Of course not. If she needed a ride to Walmart she would have no problem getting one, but to the hospital, the ambulance is always free. Or so it seems to many. You keep those thoughts to your self. You are used to this.
General Impression
As you walk in the room, you see the thin child, of normal size for his age, laying in bed. He shares the room with his younger brother and it is expectedly messy. Though it is a boy's room, you can smell someone was painting nails or something similar. He makes eye contact with you but gives a half hearted smile, showing signs he is tired of being sick. Looking at him makes you overcome with pity. You have forgotten you are a health care provider, often called to replace the MD who did house calls in the past. Despite how busy you are, it is not this kid's fault he is sick. He did not plan this. Despite whether a patient needs transport or not, you have a responsibility to alleviate pain and suffering, and this kid appears to be suffering in some way. This family called you for help and you have an obligation to help them.
Assessment
You talk to the kid and he is alert and oriented but appears slightly pale and tachypneic. Actually, he appears to be hyperventilating at 28 and regular but he denies any SOB and you have seen much worse on healthier patients. His skin is warm and dry and he tells you he is thirsty and hungry but cannot keep anything down.
In the meantime, your partner get vitals:
P=110, S/R
BP=90/58, manually
R=28, deep and regular
T=37.6
Pulsox=97% RA
Your partner asks you if you want to make this ALS or BLS and how do you want to get him to the truck. What is your answer? What is your general impression of this patient? Are the vitals within normal limits for a 9 year old. Does he need to go the hospital or should you call his pediatrician about scheduling an urgent office visit the next day? Would you refer the child to bee seen at the local urgicare center or clinic in the morning? Are there any additional isolation precautions you should consider? What other assessment information would you like (or need) to guide your treatment plan for this patient?
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.
ReplyDeleteThat's from an Australian perspective.
Nice post Shaggy.
ReplyDeleteI'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.
I'm thinking that it's a first presentation of type one diabetes, hence high BSL
ReplyDeletePossible, would explain the smell.
ReplyDeleteI agree with high blood sugar being a distinct possibility. Abdominal tenderness would additionally increase suspicion of DKA. ETCO2 may be beneficial in assessment.
ReplyDeleteA 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.
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.
ReplyDeleteakroeze.
ReplyDeleteWhat type of reading would you expect for ETCO2?
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).
ReplyDeleteEither 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 not 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.
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.
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?
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.
Unless this is a very 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.
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.
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.
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.
ReplyDeleteI'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 is
Huffing came to mind initially but after the full presentation I'd be getting a BGL to see if hes hyperglycemic.
ReplyDeleteMy rationale:
1. Acetone smell of DKA is supposedly classic, I've smelt it a couple of times but seen plenty that havent.
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.
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.
So besides BGL, I would also want an ETCO2, ECG, temp, and further history including recent fluid intake, weight loss, and urinary habits.
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.
ReplyDeleteahhh the old Kussmal's respirations.
ReplyDeleteNothing gets past you damned Aussies! I will post the second part tomorrow. I think everyone is on the right track.
ReplyDeleteBy 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*
At least for the most part. :)
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.
ReplyDelete