Worried Mother!

[Just Plain Ruff]

ok, let's see what our resident kiwitraumatologiststaffconsultoxygenthief has to say about that.

[Aussieaid]

My treatment plans: Mother- Severe DKA with aspiration and coma possibly caused by the DKA or complication of cerebral edema (which is more rare in adults with DKA)- RSI intubation to secure her airway if in protocols. With the evidence of vomiting I would prefer not to put a supraglottic airway in and risk her waking up and gagging and vomiting further. OGT straight after intubation. 2 IVs with at least 2 liters going in fast bolus, cardiac monitor, ETCO2 get her to the hospital - adult. (If the children's hospital is a free standing one then they will not take an adult when the adult hospital is 5 mins away. The children's hospital where I worked at would have freaked if you brought this patient into them. If they are connected to an adult hospital then they wouldn't have said the nearest adult one is 5 mins away.)

Baby: Severely dehydrated and acidotic - critical condition. Needs 2 IV's (or go straight to an IO since you will be lucky to find a vein on him and he needs immediate aggressive fluid resuscitation) with immediate fast 20ml/kg NS bolus and repeat with probably at least 2 more fast ones until stable. I am very concerned about his HR but his age would be helpful in guiding how bad it is. If he is a neonate than a HR of 150 with that severity of dehydration...lethargic, flaccid, skin tenting is a poor sign as i would say he is starting to brady down. If it is an older baby then it is still lower than I would expect it to be with the degree of dehydration he is showing. You would NEVER attempt to feed this baby orally in his condition. He is critical right now. His glucose is most likely low and will need 2-4 ml/kg of Dextrose 10-12.5% if under 4 weeks or Dextrose 25% if older than that. Repeat as required to stabilize his glucose. I would even consider intubating this baby as well. He is in very poor state. If he doesn't start to improve after a couple of fast fluid boluses I would be intubating him. He also needs to be covered with blankets and warmed up as well immediately. He needs to go to a dedicated children's hospital especially if it is closer. More vital signs on this baby would be a good thing and he needs cardiac monitor as well as temperature control (place a wrapped warming pad under him if you have one).

[Just Plain Ruff]

Aussieaid, i couldn't have treated these two better myself.

I don't think Id' have added a thing other than instead of trying to look for a vein, I'm probably going to go for the IO first. I'll look for 30 seconds but after that it's IO time.

[Kiwiology]

I would tube this lady as quick as I could ... If there is crud further down in the lungs there is not much you are going to be able to do about it unless you can do some deeper suctioning when she is tubed. Secure the airway and do the best you can from there.

Thanks for that mate, your thoughts almost mirror my own, I had considered deep tracheobronchial suctioning as well but wasn't sure if we tubed her if it would improve her oxygenation but perhaps I did not place as much emphasis on total protection of the airway as I should.

I was actually curious what his take on her acid/base status was and what effects he thought this had on her mitochondria as well as the regulation of tRNA.

Well off the top of my head .... DKA causes metabolic acidosis because hypoinsulinameia reverses lypogenesis (induced lypolysis) releasing free fatty acids from adipose tissue into the blood which go to the liver, are beta oxidised into pyruvate and Acetyl CoA which get used to produce ATP through oxidative phosphorylation in the mitochondria. In addition to the free fatty acids being released from storage the beta oxidation spiral produces beta hydroxybutyric acid as a byproduct, further aggravating acidosis.

Generally speaking acidosis will reduce enzyme activity because the active sites are denatured or something like that; I briefly remember covering that in biochemistry. As to the exact effect on mitochondria / electron transport chain and the F₀F₁ATPase I am not sure.

Oh and the only thing he's gonna encourage me to do is eventually go to medical school; you know its possible to become a Doctor with two years training and a smart phone now (I wish! five years my bottom!)

[Just Plain Ruff]

Oh and the only thing he's gonna encourage me to do is eventually go to medical school; you know its possible to become a Doctor with two years training and a smart phone now (I wish! five years my bottom!)

. You mean kiwiland and Nigeria right

[Kiwiology]

. You mean kiwiland and Nigeria right

Sure, actually a lot of the Doctors who come from funny Middle East countries are absolutely fantastic clinically and very friendly; so much more so than "Western" Doctors who are often very brisk; walk in, palpate this, mumble something and walk out never mind the patient is covered in faeces in a messy bed and their tummy is so empty the hunger pangs measure on the Richter scale.

An interesting comparison

US: Four years pre-med + four years med + one intern year + three years vocational training = Attending Physician

NZ: One year pre-med + four years med + one intern year + two house surgeon* years + five years vocational training = Consultant Physician

* the Senior House Officer year (second post-graduate year) can (and often is) spent entirely in ED for those who want to register with the Australasian College for Emergency Medicine

So lets see if I start right now I'll be THIRTY NINE when I'm a Consultant ... ugh that's OLD

[Aussieaid]

I would have to say that Nigeria definitely would be a "funny Middle Eastern Country" as it isn't even in the Middle East!

Intubating for deep suctioning is not the reason for intubation in this lady. Yes it will help with better suctioning than a supraglottic airway but you are not going to be passing a suction catheter beyond the carina (or end of the ETT for that matter), or going anywhere near the bronchials and the fluid is already deep in the lungs at this point.

Intubation in aspiration pneumonia is to protect the lungs from further damage/aspiration and to manage oxygenation and ventilation as they are often seriously injured with the aspiration, rather than to facilitate suctioning. That is more of an extra benefit.

[Kiwiology]

Sounds like we are sort of thinking along the same lines; I've had several strokes telling people "ventilation is not oxygenation, just because you cram oxygen down somebodies gob does not mean you are going to oxygenate them!" and perhaps I over-believed my own rhetoric (I mean its actually correct but still perhaps not in this case);

[DartmouthDave]

Hello,

I based this scenario on a patient I saw a few months back.

The mother had DKA and was intubated for airway protection. This was difficult because she was profoundly acidotic, had marginal VS and stiff lungs. The baby was rehydrated and did well in a PedICU.

Cheers

Edited March 23, 2012 by DartmouthDave

[systemet]

I realise that I'm a little late to the party, but I'd urge some caution regarding RSI with the mother:

* There's a strong possibility that she may also be hyperkalemic, as she's got a pretty decent hyperglycemia going on. A few minutes spending a 12-lead might be worthwhile, to evaluate for obvious changes suggestive of hyperkalemia, in which case some calcium and bicarbonate might be in order.

* It might be better to avoid succinylcholine for the intubation, and use an alternate paralytic, e.g. roc, or attempt a sedation-only intubation, e.g. ketamine; or midazolam / fentanyl

* 87% isn't that terrible a saturation, even if she doesn't have pre-existing lung disease, and it's survivable, especially if she's acidotic (Bohr effect). She's also likely been sick for some time, so a few minutes here or there to evaluate her thoroughly isn't going to be the end of the world.

Thanks for the scenario, DartmouthDave.