The learners receive a call from a peripheral hospital about transferring an unwell 8-year-old girl with new DKA. She has been incorrectly managed, receiving a 20cc/kg bolus for initial hypotension as well as an insulin bolus of 8 units (adult sliding scale dose for glucose of >20). The learner must perform a telephone consultation and dictate new orders. On arrival, EMS will state that they lost the IV en route, and the patient will become more somnolent in the ED. The learner should begin empiric treatment for likely cerebral edema and concurrently manage the DKA. Physical exam will show a peritonitic abdomen with guarding in the RLQ. Empiric Abx should be started for likely appendicitis. Due to decreasing neurologic status and vomiting, the patient will eventually require an advanced airway. The challenge is to optimize the peri-intubation course and ventilation to allow for compensation of her metabolic acidosis.
An 8 year old girl who has been tired and “unwell” for several days presents to the ED with an acute decline in her mental status. She is confused and lethargic. It becomes quickly apparent that the child is in DKA and requires immediate treatment. Due to decreasing neurologic status and vomiting, she eventually requires an advanced airway. The challenge is to optimize the peri-intubation course and to appropriately ventilate to allow for compensation of her metabolic acidosis.