endocrine, genetics, and fluids and electrolytes peds unit

hypotonic solutions

• Lower osmolarity than blood

• 0.45% NACL (½ NS)

• 0.2% NACL

hypertonic solutions

• Higher osmolarity than blood

• 1.5%, 3%, or 5% NACL

• D5NS

• D5LR

isotonic solutions

• Similar osmolarity to blood

• 0.9% NACL (NS)

• LR

• D5W

is sodium intracellular or extracellular

extracellular

sodium function

regulates BP

is potassium intracellular or extracellular

intracellular

potassium function

contractility of muscles

isotonic dehydration

electrolyte and water deficits

hypotonic dehydration

 electrolyte deficit exceeds the water deficit (hyponatremic)

hypertonic dehydration

water loss exceeds electrolyte loss (hypernatremic)

mild dehydration treatment

• ORS 50 mL/kg

• Supportive care at home

moderate dehydration treatment

• ORS 100 mL/kg

• Zofran

severe dehydration treatment

• IVF 20 mL/kg

  • Usually isotonic such as NS or LR

• Bolus then maintenance IVF

water intoxication

Excessive ingestion of electrolyte free fluids

water intoxication symptoms

Irritable, somnolence, headache, vomiting, diarrhea, seizures

what causes edema

Defect in cardiovascular circulation or failure in lymphatic drainage

treatment for water intoxication

• Address the cause

• Careful skin care

• Intake and output

hypernatremia causes

• Dehydration

• Diabetes insipidus

  • Low ADH

• Renal disease

• Insufficient breast milk intake in neonate

hypernatremia symptoms

• sodium level greater than 150

• Oliguria

• Intense thirst

• Dry, sticky, mucus membranes

• N/V

hypernatremia treatment

• Monitor neuro status

• Administer IVF

• Labs

• Assist with lactation support for breastfeeding mothers

hyponatremia causes

• Fever

• Excessive sweating

• Increased water intake

• Burns

• DKA

• Vomiting and diarrhea

hyponatremia symptoms

• sodium level less than 130

• Weakness

• Dizziness

• Decreased BP

• Letharg

hyponatremia treatment

• Monitor I and O

• Administer IVF with appropriate saline concentration

hyperkalemia causes

• Renal disease

• Severe dehydration

• Burns

• Potassium sparing diuretics

• Crush injuries

• Associated with metabolic acidosis

hyperkalemia symptoms

• potassium level greater than 5.0

• Muscle weakness

• Twitching

• Hyperreflexia

• EKG changes

hyperkalemia treatment

• Monitor vitals and EKG

• Administer IVF

• Monitor K level

hypokalemia causes

• Starvation

• Vomiting and diarrhea

• IV administration of insulin in DKA

• Diuretics

hypokalemia symptoms

• potassium levels less than 3.5

• Muscle weakness, cramping

• Hyporeflexia

• Hyponatremia

• Fatigue

• Irritability

hypokalemia treatment

• Monitor vitals, including EKG

• Assess renal output before potassium administration

• Slowly administer IV potassium replacement

• If taking PO offer high potassium foods and fluids

hypercalcemia causes

• Prolonged immobilization

• Renal disease

• Hyperparathyroidism

• Hyperthyroidism

hypercalcemia symptoms

• calcium level greater than 10.6

• Constipation

• Weakness

• Fatigue

• N/V

• Dry mouth

• Bradycardia

• Cardiac arrest

hypercalcemia treatment

• Monitor serum calcium levels

• Monitor EKG

hypocalcemia causes

• Vitamin D deficiency

• Hypoparathyroidism

• Advanced renal insufficiency

hypocalcemia symptoms

• calcium level less than 8.5

• Tetany

• Cardiac arrest

• Hypotension

• Neuromuscular irritability

• Tingling of distal extremities

hypocalcemia treatment

• Administer calcium replacements

  • SLOWLY

• Monitor serum calcium, vitamin D, and parathyroid levels

respiratory acidosis

• inadequate breathing causes CO2 to accumulate

• CO2 > 45

• pH < 7.35

respiratory acidosis causes

• Aspiration

• Head injury

• Sedatives

• Muscular dystrophy

• pneumothorax

metabolic acidosis

• Normal metabolism is impaired resulting in acid formation

• HCO3 < 22

• pH < 7.35

metabolic acidosis causes

• DKA, renal failure

• Loss of bicarb

respiratory alkalosis

• When breathing is beyond adequate (hyperventilation)

• pH greater than 7.45

• CO2 less than 35

metabolic alkalosis

• Intracellular shift or loss of hydrogen atoms

• HCO3 greater than 26

• pH greater than 7.45

respiratory alkalosis causes

• Hyperventilation

• Asthma

• Pulmonary embolism

• Brain tumor

• Stroke

metabolic alkalosis causes

• Decrease in acid

  • Severe bouts of vomiting

  • Gastric suctioning

• Increase in bicarb

  • Antacids

  • Steroids

metabolic alkalosis treatment

• Address the cause

• Saline infusion

• Replace K and Mg

• Stop meds causing problems

what pituitary hormones are decreased in hypopituitarism

• Growth hormone

• Thyroid stimulating hormone

• Gonadotropins (LH or FSH)

• Corticotropic hormones

GH deficiency causes

• Idiopathic

• CNS infection/disease

• Infarction of pituitary gland

• Tumors of pituitary or hypothalamus

• Brain trauma

• Chemo

GH deficiency symptoms

• Normal birth weight and length

• Height below 3rd percentile

• Overweight

• Youthful facial features

• Delayed bone age

GH deficiency treatment

GH replacement

pituitary hyperfunction

• Excessive secretion of growth hormone before the closure of epiphyseal shafts 

• Often due to pituitary adenoma

pituitary hyperfunction symptoms

• Can grow 7-8 feet tall

• Acromegaly if continues after growth plates close

pituitary hyperfunction treatment

• Treatment related to cause

• Growth cannot be reversed

• May need pituitary hormone replacements after surgery

• Emotional support

when does precocious puberty in males

age 9

when does precocious puberty in females

Females less than 7 in white and less than 6 in black

precocious puberty full puberty

Hypothalamic gonadotropin releasing hormone

precocious puberty partial puberty

Abnormal levels of estrogen or testosterone

precocious puberty symptoms

• Breast development

• Enlargement of testes/penis

• Pubic or underarm hair

• Growth spurts

• Body odor

• Menarche

• Acne

precocious puberty treatment

• treat underlying cause

  • Central: LH release hormone

  • GH

• 50% of causes stop on own

• Psychological support

hypothyroidism

• Deficiency in secretion of thyroid hormone

• Congenital or acquired

hypothyroidism congenital symptoms

• symptoms occur if left untreated

  • Thick, protruding tongue

  • Hypotonia

  • Bradycardia

  • Large posterior fontanel

  • Prolonged neonatal jaundice

  • Difficulty feeding

  • Hypothermia

hypothyroidism acquired symptoms

• Decreased appetite

• Thinning hair

• Bradycardia

• Depressed reflexes

• Slowed growth

• Fatigue

• Constipation

hypothyroidism treatment

levothyroxine

addison’s disease

Insufficient cortisol and aldosterone production from adrenal glands

addisons disease early symptoms

• Increased irritability

• Poor feeding

• Headache

• Diffuse abdominal pain

• Weakness

• N/V

• Diarrhea

addisons disease late symptoms

• Fever

• CNS involvement

  • Nuchal rigidity

  • Convulsions

  • Stupor

  • Coma

• Shock like state

  • Weakened pulse

  • Decreased BP

  • Shallow respirations

  • Cold and clammy skin

  • Cyanosis

addisons disease treatment

• ACTH stimulation test

• Replace cortisol and aldosterone

• May be able to do oral hydrocortisone and lots of salt

• May need higher doses during stressful times

congenital adrenal hyperplasia

• Increased ACTH

• Adrenal hyperplasia

  • Increased cortisol for compensation

  • Increased androgens for compensation

• Males → precocious genital development

• Females  →  may be born with varying degrees of ambiguous genitalia

congenital adrenal hyperplasia treatment

• Replace deficient hormones

• Female surgical repair

• Dietary supplementation with salt

phenylketonuria (PKA)

• Inborn error of metabolism

• Autosomal recessive

• Deficiency of the liver enzyme phenylalanine hydroxylase

what can untreated phenylketonuria (PKA) lead to

irreversible brain damage, seizures, and death

phenylketonuria (PKA) symptoms

• Growth failure (FTT)

• Frequent vomiting

• Irritability

• Hyperactivity

• Unpredictable, erratic behavior

• Cognitive impairment

• Seizures

phenylketonuria (PKA) treatment

• Diet low in phenylalanine for life

• Avoid high protein foods and aspartame

• Pregnant females must follow diet to prevent damage to fetus

what gender does turner syndrome affect

females

turner syndrome symptoms

• Short stature, webbing of neck, low hairline, drooping eyelids

• Coarctation of the aorta

• Pedal edema

• Females typically infertile

• Growth is normal until 3 years then slows

turner syndrome treatment

• Growth hormone and anabolic steroids

• Psychological support

• Monitor height and weight

• Education

• Speak to child according to chronological age

what gender goes klinefelter syndrome affect

males

klinefelter syndrome symptoms

• Long limbs

• Gynecomastia

• Hypogonadism

• Delayed puberty or lack of puberty

• Developmental delays

klinefelter syndrome treatment

• Testosterone replacement

• Breast tissue removal

• Educational support

• Speech therapy 

• Emotional support

Trisomy 21 (down syndrome) symptoms

• slanted , upturned eye

• Small ears

• Flat nose bridge

• Short neck

random glucose test results indicative of a diabetes diagnosis

greater than 200

fasting glucose test results indicative of a diabetes diagnosis

greater than 125

normal blood glucose level for a non-diabetic child

60-100

hemoglobin A1C level indicative of a diabetes diagnosis

6.5% or more

type 2 diabetes prevention

• Limit consumption of sugar sweetened beverages

• Consume recommended quantities of fruits and vegetables

• Limit screen time to no more than 2 hours per day

• Remove TV and computer screens from primary sleeping areas

• Eat breakfast daily

• Limit eating at restaurants

• Have frequent family meals in which parents and youth eat together

• Limit portion sizes

type 2 diabetes treatment

• Decreasing weight 

• Increasing physical activity

• Try to manage w/o meds

• Can use oral hypoglycemic agents and insulin

type 1 diabetes symptoms

• Polyphagia

• Polyuria

• Polydipsia

• Weight loss

• Enuresis

• Irritability

• Shortened attention span

• Dry skin

• Blurred vision

• Poor wound healing

• Fatigue

• Headache

• Frequent infections

rapid acting insulin

• novologg, humalog (aspart, lispo)

• reaches blood in 15 minutes

• peaks in 30-90 minutes

• lasts up to 5 hours

short acting (regular) insulin

• humulin R, novolin R (regular insulin)

• reaches blood within 30 minutes

• peaks in 2-4 hours

• lasts 4-8 hours

intermediate acting insulin

• novolin N, humulin N (insulin NPH)

• reaches blood in 2-6 hours

• peaks 4-14 hours

• lasts 14-20 hours

long acting insulin

• lantus (insulin glargine)

• reaches blood in 6-14 hours

• no peak or very small peak in 10-16 hoiurs

• lasts 20-24 hours

hypoglycemia symptoms

• Blurred vision

• Extreme tiredness and paleness

• Sweating

• Trembling

• Mood swings

• Hunger

• Headache

• Dizzy

hypoglycemia mild adrenergic symptoms treatment

• 10-15 g of simple, high carb substance in liquid form (juice, milk)

• Recheck in 15 minutes

• Follow with small starch-protein snack if mealtime is not imminent

moderate neuroglycopenic symptom treatment

• 10-15 g of simple, high carb substance in liquid form (juice, milk)

• Recheck in 15 minutes

• Follow with large starch-protein snack if mealtime is not imminent

severe hypoglycemic reaction symptom treatment

• unresponsive, unconscious, seizures

• glucagon

hypoglycemia nocturnal reaction symptoms treatment

• Give 10-15 g of simple carb

•  Ensure blood glucose greater than 100 mg/dL before going back to bed

hyperglycemia symptoms

• Frequent urge to urinate

• Dry mouth

• Stomach pain

• Extreme thirst

• Frequent bed wetting

• Tiredness

diabetic ketoacidosis

• medical emergency

DKA symptoms

• Ketonuria

• Fruity breath

• Ketoacidosis

• History of weight loss

• Younger children often diagnosed earlier

• Confusion, changes in LOC, cerebral edema

• Hyperglycemia

• Dehydration

• Metabolic acidosis

• Kussmaul breathing

• Fluctuating K levels

• 3 P’s

  • Polyuria

    • Glucose is highly osmotic

  • Polydipsia

    • Blood glucose levels increased which increases osmotic pressure

  • Polyphagia

    • Fats and proteins are used

DKA treatment

• Admission to PICU

• Must be on cardiac monitor due to electrolyte disturbances

• IVFs containing specific amounts of K, Na, glucose, and potassium

• Insulin drip titrated to bring down glucose slowly

  • Do not want to drop glucose more than 100 in one hour to avoid cerebral edema

  • Hourly blood glucose and neuro checks

• Monitor urine

  • Strict intake and output

  • Check for glucose and ketones

cerebral edema treatment

• Slow fluids

• Give mannitol stat

mannitol

• Drug class: diuretic (osmotic)

• Action

  • Inhibits reabsorption of water and electrolyte in nephron which decreases osmotic pressure

• Indications

  • Increased ICP

  • Oliguric renal failure

  • Edema

  • Intraocular pressure

• Side effects

  • Dehydration

  • Fluid and electrolyte imbalances

  • Phlebitis at IV site