Case of the Month
August 2004

8-year-old male — poorly responsive, lethargic

At 1316 hours Aid 2 and Medic 2 are dispatched to an 8-year-old male found by his mother semi-conscious and barely arousable. The boy’s mother meets you at the driveway with her son in her arms. He is poorly responsive as the mother hands you her son and pleads to you not to let him die. As you move toward your rig, you are impressed by the patient’s pale, cool skin, rapid respirations. You detect a pungent smell of urine that has stained his clothes (and diaper)! In the back of the rig you update the medic unit that the patient is SICK as a result of his appearance, skin signs, and rapid respirations (that you count at about 40+). The mother offers that she doesn’t know what is wrong with him as he has no significant past medical history. She states that he has not “felt well” for the past week or so and is now wearing a diaper because he has been “peeing” all over the house. The mother remains frantic while you perform initial care.

Your initial assessment of SICK is quickly followed by a focused history and physical exam which reveals: deep, sighing respirations @ 40+ BPM and no palpable radial pulse. You perform blood glucometry at the same time you apply a pediatric nonrebreather mask @ 12 liter/minute. The glucometry reading is an impressive 450mg/dl (high). You confirm the vital signs: a blood pressure of 72/palp, pulse (carotid) @ 122 BPM and weak, respirations @ 40+ BPM with bilateral breath sounds (pulse oximetry @ 92%). Your patient remains lethargic throughout the exam. You continue with a physical assessment while your partner gets a SAMPLE history from the mother who is belted in the passengers seat. As your partner starts to roll the rig for a medic intercept, she offers you a medical history as follows:

S	—	Signs/symptoms — normally developed 8-yrs male found lethargic, poorly responsive with increased respirations and cool, dry skin…smells of urine
A	—	No known allergies
M	—	none
P	—	Became increasing lethargic and poorly responsive over the past day, urine output has been off the charts (so much that mom put a diaper on him to keep him from peeing all over the house)
L	—	Early yesterday, she has been feeding him soup
E	—	Increasing lethargy, she thought he had the flu

The oxygen administration via nonrebreather mask shows good effect and pulse oximetry is now at 97%. The patient’s LOC does not change; he remains poorly responsive and lethargic during transport. Medics give you an update that they are 3 minutes out and you let them know that you approaching the rendezvous point. You continue your ongoing assessment and treatment but are challenged by the cause for his extreme lethargy and confirmed hyperglycemia.

Initial Onset of Type 1 Diabetes
This is a case of initial onset of type 1 (insulin-dependant) diabetes mellitus. Below is an outline of the presentation for these patients.

This patient’s history was one of the classic signs of hyperglycemia:

• Polydipsia ( increased fluid intake), thirst
• Polyuria (frequent urination) and nocturia (urination at night)
• Polyphagia (increased food intake — hunger)

Other symptoms

• Generalized weakness
• Malaise/lethargy
• Nausea/vomiting
• Decreased perspiration (dry skin)
• Fatigue
• Confusion
• Symptoms of associated infections and conditions (fever)

Physical: General Appearance

• Ill appearance
• Deep, rapid respirations (Kussmaul respirations) with ketotic breath (fruity, with acetone smell)
• Dry mucous membranes
• Decreased skin turgor

Vital signs

• Tachycardia
• Hypotension
• Tachypnea (rapid respirations)

Specific signs

• Confusion
• Coma
• Abdominal tenderness

One of the most common scenarios for diabetic ketoacidosis (DKA) is newly diagnosed, or previously unknown diabetes (15%).

The lesson from the case: Acquire as much patient history as possible, decide Sick or Not Sick early, initiate appropriate care and begin rapid transport with a paramedic intercept if necessary. We don’t always know the “whys” about a patient’s condition…but we can always provide care!

View optional info on Type 1 Diabetes — National Library of Medicine (external link)
View optional info on DKA treatement — American Family Physician (external link)