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Okay, so just let me know and then so really want an eye on it after the he And for those being that we're on the resource for the day and this is talking about taking from top of that. So I'm a few changes, but pick out of decays is really significant disease process that we will see and has a significant area. Holidays was 0.3% on Well, unfortunately, die as a consequence of the day. Okay. And on most of those deaths of 90% of his ass will be and Judy several edema. Okay, So you are really important. Fundamental changes today reminds DK and Children compared to adults on it's there because we want to avoid several. So just to recap, you're right area for DKA, you go clinical biochemical criteria. Your biochemical criteria are high blood sugar being above 11 acidosis is a pa is less than 70 with three or bicarbonate, 15 on ketosis, three kitchens, about three your clinical criteria or they need to be dehydrated. It's at least 3% but winning drosy on or clinically acidotic okay on. But really, you expect to see on features from both sides there. Okay, When we're assessing that, we want to know how much dehydration there is on the way. That's generally done. Accepted the way to test for of gas. That is, by going by degree of acidosis. So if Ph is less than 7.1 month of your severe end, you assume that they are 10% dehydrated on blast, then 7.2 you 7% dehydration lasted 7.3 is 5% dehydrations. I'm not just important because we use that toe, get their deficits. Food Doctor said so again, no surprises. ABCDE assessments Get them into resource. Okay, Again goes back to the very first time we have this morning, which is all over triage, which I can come in with very vague complaints may be very and vomiting not feeling well on, but it's not told you that, but sugar that we find a blood sugar of on different in high or of 20 seconds. Okay, um so get get the child and renderings us. Get appropriate people there to to look after China on Astelin early. Um, really, I only get it. Actually, we have a little possible and even the really, really set ones and so important that we get a natural way it on them. Okay, So don't be tender just to try and ask me or gas. And if needs be asked on the parent toe, left the child with them both together and then subtract on the parents were on just so that you get accurate with it. So crucial toe reminds them in terms of the foods. And so look for signs of shock as part of your ABC. That's one of the really important bets that you're really gonna focus on for a pooled cover. You feel time and check. It works centrally on peripherally. Look for tachycardia. Take attention on these will be one of the groups of patients off kids that you might look probably pressure on them. Our bolus of choices as tan Well, pick your bolus is a no no, My name's sincerely generally would say that you're gonna keep going up on and 10 Mobic, you bolus increments on after each bolus, you're gonna go back and reassess in three things that's well, so important to use those and the guy. Even further pulse is See what the response is paid into your previous one. I have another one that's there, still shocked. And once you get to four months like you know on then at stage, I think in this child is probably going to need to have towards the troops. PICU pa. See your your chin repeated pediatrician made by you. Just keep going with the Temple. Popular Bulls is and absolutely won't want to go above 60 per kilo on about staging, definitely to get my insurance on board pay, but it's helpful just to have on your hands because we'll drop about 40 mark. And you know, that started as on the sitting around on the spectrum, you need to get, um, senior people evolved quickly as you can. So the guys most couples from B S P D. Which is for a society for pediatric under college and diabetes, and they've recently changed their guidance on that trust policy hasn't changed yet. So if we would be advocating that you've fallen trust policy for my on, but it's annoying because the BSP the website has a great calculator that you grow on the news on that well, you spend it, something feels and tally. It works for the summer for you and it tells you what to do and what. You can't really use that a little bit because it's using the new protocol. Eso Then we'll come back to that. But But BSP deer there are the kind of body that would get a reminder these patients. Okay, so general principle is that you're gonna work out your deficit. Remember we said that that was based on that on the ph of the blood. You're going to give you a bolus. Is there kind of alloy toe? Have 20 miles per kilo. Bolus anything above that? You're gonna subtract from the deficit when you work right there. Fluids? They've been out there. That's there. The important thing is that you could do all the some over 40 and harsh. Okay, So and we want to. We don't want Teo have this daycare resolving in the next 12 ours. We want to top of still resolution and ideally it for you hours. Because if you get to put late, you're further increase risk of several lately, Not okay, So we'll come back the samples, because probably were something fighting that I read. That it doesn't make sense so and just to remind us that and pediatrics is we've been different models again where we delay the insulin by two hours. So on the me in problem and these Children is that the dehydrated doesn't produce toe, need a bunch of and concentrate better fluids. And so your food should be rolling for between one and two ers before you put your urine slop. And, uh uh, that would be fine, except the practice. And just a sign. Know if you've got Sinus, you know you have diabetes, and then we have on our own insulin, and then you would stop the short acting insulin. But keep your long acting insulin for that to see. It was the principal red alerts method. Go over these fancy polyps in a minute and turn that pump off. Okay, what's the one and most important thing taken point here is full of the guidelines for the guidelines. Get the get the booklet in your hand, and then read it on that side. I take, um, points are potassium. It's from the fluids from there. Okay. And ask what? Here? Seniors with the cross. If you don't, we're not going for 80 pages on the Celexa should be seen. Your foot holder may. If the child is sick, um, and red flags, it'll go for a while. The child is on the fluids. Are you lose? That would make you think that they're trying to can start develop several Adina so as that accumulates child's gonna become increasingly drives a on maybe eventually developed seizures and coma and about Concerta. If it's just a simple headache or no zero belittling on dislocated serious. So if that's the kiss wouldn't need to do is you need Teo exclude that you have to check blood sugar and make sure that hasn't just probably dying. And then I I put places like and we're gonna give them some hypertonic ceiling on. That's more my 3% and three miles biking little 3% and safely on. But we would probably stop their foods initially and then restart half. Three. They were on and but on once or stable one began a CT scan on they will most definitely going to be a CT advanced stage. Okay, so again, even task like a three year senior pediatricians are selecting. So the points every they are assassins child's in front of you getting accurate were really cold for Senior Helper. Early on, think of your goals. Fluids work with your, uh, collections carefully and then walls within close. Like so. Any questions? They're just before we go on. Teo, let me start you. Yeah. Okay. Your questions yet? So we'll just plan everybody here. Um, okay. Okay. Okay. Do you mind coming fast as this child? Jack Daniel. He hasn't mean I'm eating three days moment. He's leaving the rating high. Want to be going high, so I don't have actual you. So he's able to chat on yourself in and I said So you get started with a B C. D. In terms of a, that's normal. Space is fairly stable. The baby. So it turns out they will do the trickiest. Looks like the the Casodex functions look good spot, but the time they just in the class. So there's normal resident precautions. I am a little air and probably just call me if you get me a problem. I just get Those are carnal earth media. So for two before that, treating a 19 magic fork said I okay, just working for the exam the copy. Good. Get hospital the child that there's some idea what was hardly 174. Okay. And the pressure is running off 9. 79. But he worked for that flow. So what I do this time is on our lab that we did for this child. And he is your jewels is 30,000 ft. You total three a b c and fashion to what is the way. And it may be a perfect way. Your mother. Yeah. Machine about big. Thank you. And so we're going to get the board. My suspicion with this time this time take a reason. I think that constitute a newly elevated blood sugar. So the blood sugar on a horrible reaction high, and I'm not gonna be. And it is. I know my sugar and occasional What's that? And then the guys to call any kind of scent the gas away. And so, whatever we and look at that, we'll give it a I don't have that. Okay, so we are going to pull this here soon because the first full of this child 6.9 okay. To this child, my criteria DKA sugar and high. Probably a female Okay. That three day and 20 minutes just completed the first full of a of the way again, lifting to the chance with weight. And so again before. And so with this child, er is some improvement and the fall So the first rule of But that would be a bit of dry. Be over another bullet. Okay, well, through our second bullet with 3 79 normal feeling okay with this child is early old by DK. Okay, the initial power is initially definitely you bored. You don't consider on doing anything else to be on the first two yards from in terms of the detainee guidelines and what followed. Be and see the letter with the K. Just maybe around. Obviously. You're 80 CD assessment on, then you want to get your flu? Yeah, in terms of being a mom, first little giving Children, you don't consider giving it until after the yard. And so in this child. And we've given this lease and we also with the fullest but another 47 over fluid requirements for the next 48 hours. That's okay with being on. The incidence is required for that age on the old one and the percentage deficit of the child is because whenever that DKA be moving, the high blood sugars alternate for several days. They could be 67 levers. Negative problems. You have to take up to a point whenever you are calculated your flu requirements. It's important that you don't do that. The bathroom. Do you have enough time in DKA? Step aside. Another coli to go through this guy's like anything till it clears. Can't because of the lesions can be it'll. And you on another called it twice in the child from your initial management in terms of your and you will complete and the Muse Mints requirement level of disease of ours. Another thing you want to consider a child is really where their final destination, any divided department. Do this check in with the beauty. Hey, he had nine. And this child is like into me to the African. Care to be talking about only with pediasure. Okay, so, um, we were having about because they they burn. Supposed to end in the middle of that was it was a real versus evil. Very stupid. I am. I missed the end of the simulation real life because the stage left except T. O. C. Was down in any way just to reassure you that are you on camera both on extra to think about you and repetitive sounds at the at the actual American say, Um okay, so carbohydrates, I thought, Well, I think it was already on. The child was quite sick, and you never were able to do any of the serious expend on treatment as we saw the able to identify very relieving the child high blood sugar and to the tree eyes. Nurses were concerned and immediately brought the child to re such so That was good triaging. And I think they're working, really not sure about taking a political I finally we didn't delay that, and I also find it useful to us by population and be still not child's and age. And you tend hernia on the access started just initial knowledge mint very quickly in terms of the fluids, and I felt it was with We don't priority to write the terms of just and got the fluid onboard, a reassess and not not going to worry about everything else you are doing. The line is the Pravachol and I just could be by reassessing and not that considering getting like the child was going from here on what other help her and put me in again. So I think overall, it went well. Just I'm trying to keep this. I think that's from from coming in. This situation, sometimes you come in, is quite chaotic and great stress stressful. And also it'll definitely get IV access because these kids will be really clap doing the beans. They're hard to find sometimes, and team members could get just rub or foot. Wasn't time do that on also, Then we're having this big of the protocol, and we start like acid, the end of the dads. And it's just kind of a better a recipe for disaster because the parents were standing there watching or less involved, and it doesn't often still very much confidence. So I think it's really important for us is productions toe? Get alongside on, look after the patient first. So on Botox, to them, explain what's happening. Explained that it might be hard to get a line and not first line that just get something in. Even if it's only a blue. Just get some access and that you get going with some fluids or from what you give me a couple of bullets is then it's much easier to get a second lane later on, which is about a matter of a bigger on then, as you said and rightly so on. And you know you've got that time than before you started on the suburbs for the maintenance. There's touch ago. I always have a recommended. You be in a resource, of course, the baby next the worth. It's empty and a couple of years often, and I kind of have to get for one of the peace team, doctor's, our nurses and genital kelation and then something from Artie. Do the calculation and kind of independent label another and then make sure you didn't see it on. Sir. Um, just kind of almost describe rate that you've done the right thing. Course you could make a mistake because of you, but I think just to to a religion separately and make sure that the murderer all correct. So just run through a few and slay just again. To re it is for a hammer home. Some of these points I never want talk about the subject because that's about that folks get quite worked over. So just to recap, it was a 10 year old boy who come in with a few days history of diarrhea, vomiting, no prior diagnosis of diabetes. Um, actually, I've fairly gastroenteritis history, but triage Nurse on both through the b m on. I was just reading high on the water, so it was made them to race us. Wait to get started on ABC, Man, sing your stuff there. Test. Ask the patient. On with the sugars area was patent. We fide Haifa lock surgeon on with memory mask and has a risk. His breathing He had a small breathing with a high risk for surgery. It's on dots were okay on the Eiffel. Oxygen on We're going to see he was clinically showing the problem, covering full time cardio on display. Pressure was in the low side, and we'll make sure we got side of the access with some bloods off on desserts. Um, bolus is to the bolus. And as Tamils pick a low of normal ceiling again, just a point. Often something to get you get lying until these pens, but with the new blood will come out again because I'm sure dry and dehydrated. So I just need a expecting like sometimes you go where you okay, but you think it's not, It's not and just take out. But often times actually is in the V in on day just that there isn't a blood and the vision to try so and give a good flushing. Just go ahead and get that first boss and get it. And if your pressure's is DKA all stage of pain and then yes, that your d really important Because again, that's what the serial examinations, what we're looking for. Several of the monster was at your pre school or and way we know that. Look, this is high saturated eyes. I think about all the toxins or or poisons that might be causing this presentation. Well, that wasn't the case here. Be able t e You look for other sides of infection that might be precipitated this DKA. So it's a general examination toe proposes, and you're wet flag. So just run through again. Disturb the capital e again. I always just have the kit that and when you're in the social, gonna go to that a patent on the wall put in the child's and the birth, and I will bring it up and asked me of weird where you can put in the Actually it again really be pushing that you try and get an actual week for these cuts and that I had that will bring you up all of your emergency and calculations. But and we should know what the went flying is. Well, that's good practice to have it in your head. So and the way it thiola kind of calculation is an age plus four times to about those underestimated, especially older. It gets on. So again, that's part of why we use the iPod, because it's more accurate way estimation for you. So this wasn't asked him it. We have 37 kg. Your energy is your energy for a DC cardioversion on its four gels, but you and then you right up to the nearest adding the defense. That would be $200 a shot, and your chip is a divided by four plus four last hand away for 2.5, plus your sex life. You know it's right. Three on the right, one above one blue the real. You get your flares and or 10 miles per kilo of unopened names that ceiling, so it's 10 times 3 37 which is 3 70. You're the Rowasa enemas, 0.1 mg per Q. So that's 337 mg. Adrenaline is 0.1 mils per kilo of one in 10,000 or not your cardiac arrest. Adrenaline on your glucose is 10 miles, but he knew of 10% Baxter's. It's not 74. It's just good practice to keep Can practice on that doing that relate when you have the iPod and just do you have because I'm trying to kind of give me an emergency thing is that you might need to be able to pull from the back of your hand. So we're just gonna and talk with that for the fluids, because again, that's something that people get quite worked up by. And I was like, because we do know that the fluid is coming dangerous, so we're going to talk to me about about the deficit. So home health of the deficit. What we said is the amount of dehydration. We asked me the date of Asian by the pH. So the Ph is 6.9. That means his temper 78 to the deficit is 10% times 37 has weight times 10. So that's 3700. So that's harmony, Males. Here's that and deplete. Okay? And he needs that. But actually about then is a divorce is that we give Solu Leslie boy and I have two losses of 10 miles. Potato off. Not when I entered ceiling. So that was 7 40 males. Okay, but if you remember back and pro collects a long as you have up to 20 miles particular bullets, that doesn't come into the calculations that that makes sense. So that's seven or 40. Hasn't actually I used this calculation. If he had had another 10 multiple lists, stop, take up to 30 miles per kilo and total on. In terms of that, you reduced the third bullet that she got 10 more predictable with denticle cramps. Calculation. Okay, but he's a liar. 20 miles potato bolus. I hope I make sense. And the meat since then is for this And for this week, it between 10 and 14. He knows about that a one military per kilo per our. So again, he's 30 30 70 years. This is 37 miles per our and then your final calculation. Then you take your deficit. You know, minus any balls is about the train males, which is here with muskets. So that's 3700. And then you add and the 40th are total off your maintenance fluid. That's that's 37 times 40. It's now, which is, um, all together that could ship 547 sex for 48 hours. Define. Got my four year did not give you 14. So what you're trying to do here is your work. And I I I'm in a fluids he needs and four yards just as maintenance for our and then you're adding in his deficits, but without for yours because you want to give us a slew. Continuous infusion doesn't change it. Before, you had ours just gradually, very, very slightly. Both replace his on deficit, but also keep the medicines going. The black friends that he doesn't get more dehydrated. Okay, so that's kind of principle behind it may be nice a lot well, and but the easiest thing that is isis be in real life. And it is, um so again, I think not on it before when you have a type of daycare worth you been a third person in the summer. It's just so that you're inside and with themselves and make sure you're happy in your head that you didn't correct weight. But the are confusing. And the other thing you said to quickly say is that this is very well by March. So the child doesn't have anything else really apart from his IV fluids. Okay, and once on the word sometimes and the nurses in the world will allow them to tear drink on tope. But that has been very carefully measured and then deducted off. The fluids are ongoing. Okay, so and takes clap that have worked on their part. Okay, and actually said with delayed but 13 R's on its portable minutes, pick it up for our So that's 3.7 miles per hour. Once that starts and again, we have that pretty prefilled syringes, which are really great for just happens to get through that. Okay, scratching your hands. Sometimes it is about double Dutch, but I guess I said before, just take it off to the side and get through the protocol. What kind of walk you through? What you're doing, Okay. Another big thing to think about is potassium needs to go into those foods. So get the protocol. Tells me exactly what to do. Any questions that that's not completely bamboozled.