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Like Gary Wilkes I would wonder if this boy may have mild DKA as a first
presentation of IDDM.  The "previously well 9 yr old boy" description
doesn't tell us enough - was there any suggestion of polydipsia, polyuria or
weight loss during the preceding few weeks when the specific questions were
asked?  The absence of any such history would make the diagnosis fairly
unlikely.   I wouldn't treat as DKA  unless he was clearly dehydrated and
would not give insulin, just volume initially.
However high dose salbutamol does raise serum lactate and you may be looking
at the stress/steroid effect causing increased blood glucose plus a mild
lactic acidosis due to salbutamol.  We might see this more often if we were
doing more ABGs in asthmatics but as they hardly ever  change clinical
 management we rarely do them.   How long was he on continuous nebulisers
before the blood sample was obtained?
 
Regards,
 
Richard Aickin
Director
Children's Emergency Department
Starship Children's Health
Auckland
New Zealand
 ----------
From: owner-ped-em-l
To: Multiple recipients of list PED-EM-L
Subject: A Case
Date: Thursday, 28 March 1996 04:05AM
 
A previously well 9 year old boy presented to our emergency department with
breathlessness and wheeze.  He had no previous history of asthma although
there
was a family history of atopy.  His local doctor had given him 5 mg of
nebulised
salbutamol and 1mg/kg of prednisolone without effect.
 
On examination he had marked signs of respiratory distress.  Although alert
and
talkative he was pale with a tachycardia of 140, tachypnoea of 40,
intercostal
recessions and O2 saturation 88% in air.  Chest was hyperinflated with
symmetrical poor air entry and quiet, biphasic wheeze.  No crackles.  He was
apyrexial.  (Spinal process alignment seemed normal.)
 
We gave him constant nebulised salbutamol with an initial dose of
ipratropium,
put in a cannula and gave a further 1mg/kg of methyl prednisolone iv (local
protocol).  He improved steadily over the 2 hours he was in the ED but was
still
oxygen dependant between nebulised doses of salbutamol when he was sent to
the
paediatric ward.
 
On the paediatric ward a thorough nurse tested his urine and found large
amounts
of glucose and ketones.  The resident on the ward requested:
blood glucose- 22 mmol/l (400 mg/100 ml)
U&Es- Na 124 mmol/l, rest N
ABG- pO2= 10kpa; pCO2= 4.3kpa; ph= 7.24; be= neg 9
FBC- Hb= 12.4; WCC= 9 (60% nuets); plats= 385
CXR- hyperinflation + small, bilateral areas segmental collapse.  No
effusion.
Normal cardiac outline.
HbA1 not available until the following morning.
 
What would you do now?
 
Andrew McIntyre- Paediatric Registrar
Emergency Department, Monash Medical Centre, Melbourne.
 
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
 
The URL for the PED-EM-L Web Page is:
  http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html