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Endocrine Emergencies
CPEN REVIEW QUESTIONS
ENDOCRINE EMERGENCIES Authors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA, Chicago and Vernon Hills, IL, and Dyer, IN Section Editors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA January of 2009 marked the start of the Certified Pediatric Emergency Nurse (CPEN) examination. In support of this new certification, three times a year JEN will feature this new column supplying questions similar to those in the CPEN examination to assist in preparation for the examination. Questions, rationale for the correct answers, and references are provided here for your self-evaluation. The word “diabetes” is derived from the Greek word diabainein, which means to stand with legs apart (as in urinating) or to siphon. The most obvious sign of diabetes is excessive urination. Water passes through the body of a person with diabetes as if it were being siphoned from the mouth through the urinary system and out of the body. “Mellitus” comes from a Latin word that means sweet like honey. The urine of a person with diabetes contains extra sugar (glucose). In 1679 the physician Thomas Willis tasted the urine of a person with diabetes and described it as “wonderfully sweet” like honey.
QUESTIONS
1. Which statement is incorrect concerning diabetic ketoacidosis (DKA)? A. The onset of symptoms is gradual. B. The patient’s symptoms are likely due to taking too much
insulin. C. The patient’s skin is usually dry. D. The patient exhibits signs of or complains of excessive
thirst and frequent urination. 2. Which of the following is an early indication of possible hypoglycemia in an infant? A. Jitteriness B. Lethargy C. Increased urinary output D. Increased feeding
REFERENCES 1. Cooke D, Plotnick L. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008;29(12):431-5. 2. DeBoer S. Certified Pediatric Emergency Nurse Review: Putting It All Together. 1st ed. Dyer, IN: Peds-R-Us Medical Education; 2009. 3. Jain A, Aggarwal R, Jeeva Sankar M, Agarwal R, Deorari A, Paul V. Hypoglycemia in the newborn. Indian J Pediatr. 2010;77(10):1137-42. 4. Cranmer H, Shannon M. Pediatrics, hypoglycemia. http://emedicine. medscape.com/article/802334-overview. Accessed October 15, 2010. 5. Sergot P, Nelson L. Hyperosmolar, hyperglycemic state. http://emedicine. medscape.com/article/766804-overview. Accessed October 15, 2010.
3. Initial treatment of an unconscious 6-month-old infant with hypoglycemia would include: A. Intravenous (IV) bolus of D5W B. IV bolus of D10W C. IV bolus of D25W D. IV bolus of D50W
4. All of the following are common signs or symptoms of hyperglycemic hyperosmolar non-ketotic coma (HHNC) in patients with type II (non–insulin-dependent) diabetes except: A. Polydipsia B. Polyphagia C. Kussmaul respiration D. Polyuria
Scott DeBoer is Flight Nurse, University of Chicago Hospitals, Chicago, IL, and Founder, Peds-R-Us Medical Education, Dyer, IN. Michael Seaver is Senior Healthcare Consultant, Vernon Hills, IL. J Emerg Nurs 2011;37:261-2. Available online 25 March 2011. 0099-1767/$36.00
5. After initiating IV fluids and an insulin drip, the emergency nurse should assess the patient for which potentially fatal treatment-related complication? A. HHNC or hyperosmolar hyperglycemic non-ketotic syndrome B. Acute renal failure
Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
C. Cerebral edema
doi: 10.1016/j.jen.2010.11.016
D. Acute hepatic failure
May 2011
VOLUME 37 • ISSUE 3
WWW.JENONLINE.ORG
261
CPEN REVIEW QUESTIONS/DeBoer and Seaver
ANSWERS 1. Correct answer: B DKA is caused by not enough insulin, not too much insulin. Insufficient insulin leads to hyperglycemia, not hypoglycemia. The symptoms associated with DKA generally develop gradually, and remembering the “3 poly’s” can help: polyuria (pee all the time), polydipsia (drink all the time), and polyphagia (eat all the time.) The skin in DKA is dry because of dehydration from polyuria. Glucosuria is also a common symptom, sometimes leading us to think of these kids as “Sweet Peas” spelled just slightly differently. Even though there is way too much sugar in the bloodstream, the real problem is that, because of the lack of insulin, the sugar cannot get into the cell. So the body tries to get more sugar by eating more (polyphagia). Polyuria comes as the body tries to “pee out” the extra sugar, and polydipsia is an attempt to “dilute” the extra sugar floating around the bloodstream and avoid having to pee sugar cubes. Hypoglycemic patients commonly have a fairly rapid onset of symptoms, including diaphoresis and mental status changes, but not always. Cooke and Plotnick,1 431; DeBoer,2 336. 2. Correct answer: A As the brain uses glucose incredibly quickly, one of the earliest signs of hypoglycemia in infants is jitteriness. To be “happy,” brains only want 3 things: blood, oxygen, and glucose. If you deprive a brain of 1 of these things for any period of time (or, even worse, 2 or 3), you have a very unhappy brain. When assessing infants, if something does not seem right, one of the first interventions should be to check a finger- or heel-stick sugar level. Hypoglycemic emergency nurses get cranky . . . babies get jittery. DeBoer,2 336; Jain et al.3 3. Correct answer: C A 6-month-old child with hypoglycemia should receive D25W. If D25W is not immediately available, simply dilute D50W 1:1 with sterile water if this is permissible in your facility. D50W boluses are
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most often reserved for teens and adults. In the neonatal ICU, D5W is commonly used with micro-premature babies, whereas D10W is given to most of all the other babies. Simply, the older and bigger you become, the more sugar you receive. DeBoer,2 336; Cranmer and Shannon.4 4. Correct answer: C Kussmaul respirations are like prank callers on the phone; they breathe really fast and deep. The presence of Kussmaul respirations is related to the body’s attempt to “blow off” excess CO2 and is not common with type II, or non–insulin-dependent, diabetes. In patients in HHNC from non–insulin-dependent diabetes, the body produces some, but not nearly enough, insulin. The insulin present is usually sufficient to prevent the extensive breakdown of fats for energy, thus avoiding the metabolic acidosis that is a byproduct of the process of breaking down fatty acids. Consequently, metabolic acidosis does not typically occur, and therefore no compensatory Kussmaul respirations are needed. As mentioned in the answer to question 1, the “3 poly’s” are common with hyperglycemia. DeBoer,2 337; Sergot and Nelson.5 5. Correct answer: C The most feared complication of DKA management is that of cerebral edema. Remember, DKA did not develop in the patient in a few hours, and therefore you should not try to fix it in just a few hours. Rapid correction of DKA can lead to cerebral edema, a potentially fatal condition, and can be detected via physical examination or computed tomography scan. The treatment for cerebral edema includes airway support, mannitol, and/or hypertonic saline solution. Management of DKA has definitely changed over the years, and current recommendations include very cautious fluid resuscitation, very rare use of sodium bicarbonate (even with pH <7.0), and very rare use of insulin boluses (just start the drip). HHNC occurs primarily in patients with type II (non–insulin-dependent) diabetes and is a very different condition than DKA. Neither renal nor hepatic failure is a likely treatment complication with DKA. Cooke and Plotnick,1 434; DeBoer,2 340.
VOLUME 37 • ISSUE 3 May 2011
ENDOCRINE EMERGENCIES Authors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA, Chicago and Vernon Hills, IL, and Dyer, IN Section Editors: Scott DeBoer, RN, MSN, CEN, CPEN, CCRN, CFRN, EMT-P, and Michael Seaver, RN, BA January of 2009 marked the start of the Certified Pediatric Emergency Nurse (CPEN) examination. In support of this new certification, three times a year JEN will feature this new column supplying questions similar to those in the CPEN examination to assist in preparation for the examination. Questions, rationale for the correct answers, and references are provided here for your self-evaluation. The word “diabetes” is derived from the Greek word diabainein, which means to stand with legs apart (as in urinating) or to siphon. The most obvious sign of diabetes is excessive urination. Water passes through the body of a person with diabetes as if it were being siphoned from the mouth through the urinary system and out of the body. “Mellitus” comes from a Latin word that means sweet like honey. The urine of a person with diabetes contains extra sugar (glucose). In 1679 the physician Thomas Willis tasted the urine of a person with diabetes and described it as “wonderfully sweet” like honey.
QUESTIONS
1. Which statement is incorrect concerning diabetic ketoacidosis (DKA)? A. The onset of symptoms is gradual. B. The patient’s symptoms are likely due to taking too much
insulin. C. The patient’s skin is usually dry. D. The patient exhibits signs of or complains of excessive
thirst and frequent urination. 2. Which of the following is an early indication of possible hypoglycemia in an infant? A. Jitteriness B. Lethargy C. Increased urinary output D. Increased feeding
REFERENCES 1. Cooke D, Plotnick L. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008;29(12):431-5. 2. DeBoer S. Certified Pediatric Emergency Nurse Review: Putting It All Together. 1st ed. Dyer, IN: Peds-R-Us Medical Education; 2009. 3. Jain A, Aggarwal R, Jeeva Sankar M, Agarwal R, Deorari A, Paul V. Hypoglycemia in the newborn. Indian J Pediatr. 2010;77(10):1137-42. 4. Cranmer H, Shannon M. Pediatrics, hypoglycemia. http://emedicine. medscape.com/article/802334-overview. Accessed October 15, 2010. 5. Sergot P, Nelson L. Hyperosmolar, hyperglycemic state. http://emedicine. medscape.com/article/766804-overview. Accessed October 15, 2010.
3. Initial treatment of an unconscious 6-month-old infant with hypoglycemia would include: A. Intravenous (IV) bolus of D5W B. IV bolus of D10W C. IV bolus of D25W D. IV bolus of D50W
4. All of the following are common signs or symptoms of hyperglycemic hyperosmolar non-ketotic coma (HHNC) in patients with type II (non–insulin-dependent) diabetes except: A. Polydipsia B. Polyphagia C. Kussmaul respiration D. Polyuria
Scott DeBoer is Flight Nurse, University of Chicago Hospitals, Chicago, IL, and Founder, Peds-R-Us Medical Education, Dyer, IN. Michael Seaver is Senior Healthcare Consultant, Vernon Hills, IL. J Emerg Nurs 2011;37:261-2. Available online 25 March 2011. 0099-1767/$36.00
5. After initiating IV fluids and an insulin drip, the emergency nurse should assess the patient for which potentially fatal treatment-related complication? A. HHNC or hyperosmolar hyperglycemic non-ketotic syndrome B. Acute renal failure
Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
C. Cerebral edema
doi: 10.1016/j.jen.2010.11.016
D. Acute hepatic failure
May 2011
VOLUME 37 • ISSUE 3
WWW.JENONLINE.ORG
261
CPEN REVIEW QUESTIONS/DeBoer and Seaver
ANSWERS 1. Correct answer: B DKA is caused by not enough insulin, not too much insulin. Insufficient insulin leads to hyperglycemia, not hypoglycemia. The symptoms associated with DKA generally develop gradually, and remembering the “3 poly’s” can help: polyuria (pee all the time), polydipsia (drink all the time), and polyphagia (eat all the time.) The skin in DKA is dry because of dehydration from polyuria. Glucosuria is also a common symptom, sometimes leading us to think of these kids as “Sweet Peas” spelled just slightly differently. Even though there is way too much sugar in the bloodstream, the real problem is that, because of the lack of insulin, the sugar cannot get into the cell. So the body tries to get more sugar by eating more (polyphagia). Polyuria comes as the body tries to “pee out” the extra sugar, and polydipsia is an attempt to “dilute” the extra sugar floating around the bloodstream and avoid having to pee sugar cubes. Hypoglycemic patients commonly have a fairly rapid onset of symptoms, including diaphoresis and mental status changes, but not always. Cooke and Plotnick,1 431; DeBoer,2 336. 2. Correct answer: A As the brain uses glucose incredibly quickly, one of the earliest signs of hypoglycemia in infants is jitteriness. To be “happy,” brains only want 3 things: blood, oxygen, and glucose. If you deprive a brain of 1 of these things for any period of time (or, even worse, 2 or 3), you have a very unhappy brain. When assessing infants, if something does not seem right, one of the first interventions should be to check a finger- or heel-stick sugar level. Hypoglycemic emergency nurses get cranky . . . babies get jittery. DeBoer,2 336; Jain et al.3 3. Correct answer: C A 6-month-old child with hypoglycemia should receive D25W. If D25W is not immediately available, simply dilute D50W 1:1 with sterile water if this is permissible in your facility. D50W boluses are
262
JOURNAL OF EMERGENCY NURSING
most often reserved for teens and adults. In the neonatal ICU, D5W is commonly used with micro-premature babies, whereas D10W is given to most of all the other babies. Simply, the older and bigger you become, the more sugar you receive. DeBoer,2 336; Cranmer and Shannon.4 4. Correct answer: C Kussmaul respirations are like prank callers on the phone; they breathe really fast and deep. The presence of Kussmaul respirations is related to the body’s attempt to “blow off” excess CO2 and is not common with type II, or non–insulin-dependent, diabetes. In patients in HHNC from non–insulin-dependent diabetes, the body produces some, but not nearly enough, insulin. The insulin present is usually sufficient to prevent the extensive breakdown of fats for energy, thus avoiding the metabolic acidosis that is a byproduct of the process of breaking down fatty acids. Consequently, metabolic acidosis does not typically occur, and therefore no compensatory Kussmaul respirations are needed. As mentioned in the answer to question 1, the “3 poly’s” are common with hyperglycemia. DeBoer,2 337; Sergot and Nelson.5 5. Correct answer: C The most feared complication of DKA management is that of cerebral edema. Remember, DKA did not develop in the patient in a few hours, and therefore you should not try to fix it in just a few hours. Rapid correction of DKA can lead to cerebral edema, a potentially fatal condition, and can be detected via physical examination or computed tomography scan. The treatment for cerebral edema includes airway support, mannitol, and/or hypertonic saline solution. Management of DKA has definitely changed over the years, and current recommendations include very cautious fluid resuscitation, very rare use of sodium bicarbonate (even with pH <7.0), and very rare use of insulin boluses (just start the drip). HHNC occurs primarily in patients with type II (non–insulin-dependent) diabetes and is a very different condition than DKA. Neither renal nor hepatic failure is a likely treatment complication with DKA. Cooke and Plotnick,1 434; DeBoer,2 340.
VOLUME 37 • ISSUE 3 May 2011