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Pediatric Endocrine and Genitourinary Emergencies

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Pediatric Endocrine and Genitourinary Emergencies Gavin Greenfield Objectives Endocrine Diabetic Ketoacidosis Genitourinary Phimosis Paraphimosis Penile Entrapment ... – PowerPoint PPT presentation

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Title: Pediatric Endocrine and Genitourinary Emergencies


1
Pediatric Endocrine and Genitourinary Emergencies
  • Gavin Greenfield

2
Objectives
  • Endocrine
  • Diabetic Ketoacidosis
  • Genitourinary
  • Phimosis
  • Paraphimosis
  • Penile Entrapment
  • Balanoposthitis
  • Epididymitis
  • Testicular (spermatic cord) torsion
  • Torsion of appendix testis

3
Pediatric Type 1 DMGeneral Info
  • characterized by pancreatic islet beta-cell
    destruction mediated by immune mechanisms in
    predisposed individuals
  • classic presentation is polyuria, polydipsia,
    polyphagia, unexplained weight loss
  • presents clinically when insulin secreting
    reserve is 20 of normal
  • DKA is the initial presentation of the disease in
    25 of children

4
Case
  • 6 year old male presents with polyuria,
    polydipsia, vomiting, fruity breath odour. You
    suspect DKA. Before you are allowed to treat her
    son the mother wants to know how diabetic
    ketoacidosis develops.

5
Diabetic Ketoacidosis Pathophysiology
  • progressive insulin deficiency
  • leads to excessive glucose production and
    impaired glucose utilization
  • results in osmotic diuresis
  • resulting dehydration (stress) activates
    counter-regulatory stress hormones (epinephrine,
    glucagon, cortisol, GH)
  • insulin deficiency and elevated stress hormones
    results in lipolysis and protein metabolism
  • lipids to fatty acids to ketone bodies
    (beta-hydroxybutyrate and acetoacetate)
  • protein to ketoacids
  • ketone bodies and ketoacids result in metabolic
    acidosis

6
Diabetic Ketoacidosis Pathophysiology
7
DKA Presentation
  • polyuria, polydipsia
  • vomiting, dehydration
  • Kussmauls respiration
  • odour of acetone on breath (fruity)
  • abdominal pain or rigidity
  • cerebral obtundation and ultimately coma
  • seek out precipitating event like infection
  • others include trauma, vomiting, psychologic
    disturbances, deliberate insulin omission

8
Case
  • Mom wants to know how you can be sure of the
    diagnosis and what tests you will do.

9
Case
  • glucose 36
  • Na 130, K 5.5, HCO3 15, Cl 90
  • WBC 20
  • urine for glucose and ketones

10
DKA Diagnosis
  • hyperglycemia and glucosuria
  • ketonemia and ketonuria
  • anion gap metabolic acidosis
  • Other Lab Findings
  • leukocytosis common
  • normal or elevated serum potassium
  • total body K is almost universally low because of
    urinary excretion
  • often low measured serum sodium
  • explain

11
Case
  • How are you going to treat this 6 year old boy
    who has DKA?

12
DKA Treatment Principles
  • Ensure adequate ventilation and circulation
    (cardiovascular function)
  • Correct fluid deficits and electrolyte
    disturbances (fluid therapy)
  • Interrupt ketone and ketoacid production with
    insulin therapy and lower plasma glucose to
    minimize ongoing osmotic diuresis
  • Correct metabolic acidosis (fluids and insulin)
  • Assess for and treat any underlying causes of DKA
    (e.g., infection)
  • Closely monitor for and treat any complications
    of DKA (vital signs, neurologic monitoring)

13
DKA Treatment Fluids and Electrolytes Initial
Volume ResuscitationWhite, Diabetic
Ketoacidosis in Children, Endocrinol Metab Clin
North Am, Dec 01, 2000 29(4)657-82Rutledge J
Initial Fluid Management of Diabetic ketoacidosis
in children, Am J Emerg Med, Oct 01, 2000 18(6)
658-60
  • if clinical evidence of shock
  • 10-20 cc/kg NS over 30-60 minutes and repeat only
    if shock persists
  • if no clinical evidence of shock
  • no bolus or bolus lt 10 cc/kg

14
DKA Treatment Fluids and Electrolytes
Subsequent Resuscitation
  • Following bolus give fluids evenly over next 24
    48 hours
  • Consider giving 1.5 - 2.5 X maintenance over next
    24 hours and decrease to 1-1.5X maintenance after
    first 24 hours
  • Felner Improving management of diabetic
    ketoacidosis in children Pediatrics Sept 01,
    2001 108(3) 735-40
  • sodium, potassium, phosphate
  • excess chloride may aggravate acidosis so
    consider giving some potassium as
    potassium-phosphate
  • glucose containing solution once glucose lt 15
  • probably no role for bicarb therapy

15
DKA Treatment - Insulin
  • Bolus vs. No Bolus
  • steady state reached in 30 min even without bolus
  • no clinical trials comparing the two directly
  • if decide to bolus dose is 0.05-0.1 unit/kg R IV
  • Infusion Dose
  • 0.1 unit/kg/h R (how was this number arrived at?)
  • if no improvement in 4 hours (pH, anion gap,
    bicarb, glucose) then double infusion rate
  • as ketosis and acidosis resolve can lower
    infusion rate (usually no lower than 0.05
    unit/kg/h R)

16
Case
  • You have started your treatment with intensive
    monitoring, fluids and insulin. Labs are slowly
    normalizing. 4 hours later you note the patient
    to have a decreased level of consciousness. Mom
    says what is happening??? what did you do???

17
DKA - Complications
  • hypoglycemia, aspiration, fluid overload with CHF
  • all can be avoided with careful attention to
    details of treatment
  • Cerebral Edema
  • complication of DKA that is restricted to
    children
  • incidence 1-2
  • poor prognosis 1/3 die, 1/3 permanent
    neurological impairment
  • usually occurs during treatment of DKA

18
DKA Complications Cerebral Edema
  • Presentation
  • Coma or declining or fluctuating mental status
  • Dilated, unresponsive, sluggish, or unequal
    pupils
  • Papilledema (a late finding)
  • Sudden development of hypertension not detected
    at presentation
  • Development of hypotension or bradycardia
  • An unexpected decline in urine output without
    clinical improvement or tapering of intravenous
    fluids (SIADH)

19
DKA Complications Cerebral Edema
  • Proposed Mechanisms
  • rapid shifts in extracellular and intracellular
    fluid and osmolality
  • CNS acidosis
  • cerebral hypoxia
  • excess fluid administration
  • Glaser et al. Risk factors for cerebral edema in
    children with diabetic ketoacidosis. NEJM Vol
    344 Jan 25, 2001 No.4 264-9
  • independent risk factors for cerebral edema in
    children with DKA low pCO2, increased BUN,
    treatment with bicarbonate

20
Case
  • How can we treat this 6 year olds swollen brain?

21
DKA Complications Cerebral Edema - Treatment
  • IV Mannitol 0.2-1.0 g/kg over 30 minutes, repeat
    prn
  • decrease IV rate
  • Hyperventilation
  • ICU

22
Case 2
  • 6 year old sister of above pt presents with 3
    weeks of polyuria, polydipsia and minimal weight
    loss. Glucose 20, Na 140, K 4.0, Cl 105, HCO3
    25, urine glucose , no urine ketones. Manage.

23
1st presentation of Type 1 DM, not in DKA (75 of
patients)
  • subcutaneous injections of insulin
  • usually start with regular insulin q 6-8 hours,
    total daily dose of 0.3-1.0 units/kg
  • simultaneous monitoring of blood glucose
    concentration and adjustment of insulin dosing
  • after 1-2 days of regular insulin estimate total
    daily requirement and change to combined
    intermediate and short acting forms
  • Referral and Education

24
Pediatric Genitourinary Emergencies
  • Phimosis and Paraphimosis
  • Penile Entrapment
  • Balanoposthitis
  • Epididymitis
  • Testicular Torsion and Torsion of Appendages

25
Genitourinary Emergencies
26
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27
Genitourinary Emergencies - Phimosis
  • inability to retract the prepuce
  • in 90 of uncircumcised males the prepuce becomes
    retractable by age of 3 years
  • can be pathologic from inflammation and scarring
    at the tip of the foreskin
  • causes include infection, poor hygiene, previous
    preputial injury with scarring (see next point)
  • forceful retraction of the foreskin can result in
    phimosis in the future from scarring
  • only reason to treat in emerg is if scarring at
    the tip of the foreskin occludes the preputial
    meatus resulting in urinary retention
  • dilate preputial meatus with hemostat

28
Genitourinary Emergencies - Paraphimosis
  • inability to reduce the proximal edematous
    foreskin (prepuce) distally over the glans penis
    into its naturally occurring position
  • resulting venous engorgement of glans can
    progress to arterial compromise and gangrene
  • true urologic emergency

29
Genitourinary Emergencies - Paraphimosis
30
Genitourinary Emergencies Paraphimosis -
Treatment
  • Proximal foreskin needs to be reduced distally
    over the glans
  • compress glans for several minutes to reduce
    edema in glans and allow foreskin to be pulled
    over
  • tightly wrap glans with elastic bandage
  • 22-25G needle to produce several puncture wounds
    in glans to drain edema fluid
  • local infiltration of constricting band with
    lidocaine followed by superficial vertical
    incision of band this decompresses the gland and
    allows foreskin reduction

31
Genitourinary Emergencies - Penile Entrapment
  • various objects can be placed around penis,
    initially occluding venous and subsequently
    arterial supply
  • hair is probably most common in kids
  • usually entrapped behind coronal (glans) ridge
  • hair may be invisible in edematous skin
  • manage with careful removal or consultation

32
Genitourinary Emergencies - Balanoposthitis
  • Balanitis is inflammation of glans
  • Posthitis is inflammation of foreskin (prepuce)
  • Treat
  • cleanse area with mild soap
  • assure adequate dryness
  • antifungal creams
  • possible circumcision
  • if secondary bacterial infection is present use
    broad spectrum antibiotic (cephalosporin)

33
Genitourinary Emergencies - Balanoposthitis
34
Case
  • 10 year old boy presents with 3 hours of lower
    abdominal pain and scrotal pain (LgtR). What is
    differential diagnosis?
  • What historical features can we use to sort out
    diagnosis?
  • Kadish and Bolte, A retrospective review of
    pediatric patients with epididymitis, testicular
    torsion and torsion of testicular appendages.
    Pediatrics 1998 102(1)73-6

35
Genitourinary Emergencies Epididymitis - Anatomy
36
Genitourinary Emergencies - Epididymitis
  • Presentation
  • unilateral scrotal swelling and/or tenderness,
    maximal over the head of the epididymis
  • often associated orchitis
  • occasionally bilateral
  • may have erythema and edema of overlying skin
  • with/without discharge
  • redness, swelling, fever only in severe cases

37
Genitourinary Emergencies - Epididymitis
  • major differential diagnosis is torsion
  • urinalysis usually reveals pyuria
  • true infectious epididymitis rare pre-puberty
  • if occurs pre-pubertal consider chemical cause
    from anatomic abnormality
  • like ectopic ureter entering vas
  • retrograde urine flow up urethra to vas
  • after puberty becomes most common cause of acute
    painful scrotal swelling in young, sexually
    active boys

38
Genitourinary Emergencies Epididymitis - Anatomy
39
Genitourinary Emergencies - Epididymitis
  • Infectious
  • usually STD post pubescent (Chlamydia, Gonorrhea)
  • non STD causes include gram negative organisms
    associated with UTI, viruses, TB
  • investigate with urethral swab and urine culture
  • ultrasound can potentially be helpful
  • treat with Ceftriaxone or Cefixime doxycycline
    if STD
  • ofloxacin if enteric organisms

40
CaseKadish and Bolte, A retrospective review of
pediatric patients with epididymitis, testicular
torsion and torsion of testicular appendages.
Pediatrics 1998 102(1)73-6
  • 10 year old boy presents with 3 hours of lower
    abdominal pain and scrotal pain (LgtR). What is
    differential diagnosis?
  • What historical features can we use to sort out
    diagnosis?
  • What features on physical examination can we use
    to sort out diagnosis?

41
Genitourinary Emergencies Testicular (spermatic
cord) Torsion
42
Genitourinary Emergencies Testicular (spermatic
cord) Torsion
  • most common cause of testicular pain in boys 12
    years and older
  • uncommon in boys less than 10 but may occur at
    any age (torsion of appendix testis most common
    cause of testicular pain between 2-10)
  • typically, the at risk testis is aligned along a
    horizontal rather than a vertical axis
  • 2 types intravaginal and extravaginal

43
Genitourinary Emergencies Testicular (spermatic
cord) Torsion
  • Presentation
  • torsion typically preceded by strenuous activity
    or trauma but does occur at rest
  • pain usually sudden, severe, felt in lower
    abdominal quadrant, inguinal canal, or testis
  • often associated vomiting

44
CaseKadish and Bolte, A retrospective review
of pediatric patients with epididymitis,
testicular torsion and torsion of testicular
appendages. Pediatrics 1998 102(1)73-6Robinowit
z R. The importance of the cremasteric reflex in
acute scrotal swelling in children. J. Urol.
198413289-90
  • All 13 patients (100) with testicular torsion
    had a tender testicle and an absent cremasteric
    reflex
  • patients with testicular torsion had
    significantly greater incidence of tender
    testicle, abnormal testicular lie and absent
    cremasteric reflex when compared with patients
    with epididymitis
  • Rabinowitz reviewed 245 boys with acute scrotal
    swelling (over 7 years), no patients with a
    cremasteric reflex had a testicular torsion

45
Genitourinary Emergencies Testicular (spermatic
cord) Torsion
  • Management
  • if high suspicion emergent urological
    consultation for surgical exploration
  • if low or equivocal suspicion consider
    colour-flow duplex Doppler ultrasound or
    radionuclide scintigraphy
  • while awaiting transport attempt manual detorsion
  • need definitive treatment within 6 hours for
    testis to survive

46
Genitourinary Emergencies Testicular (spermatic
cord) TorsionManual Detorsion
  • most testes torse in a lateral to medial fashion,
    therefore initially attempt in medial to lateral
    motion (right testes counterclockwise, left
    testes clockwise)
  • painful procedure but cant use anesthesia
    because wont be able to assess relief of pain
  • worsening of patients pain should result in
    detorsion being done in the opposite direction

47
Genitourinary Emergencies Testicular (spermatic
cord) Torsion
48
Genitourinary Emergencies Testicular (spermatic
cord) Torsion
49
Genitourinary Emergencies Torsion of the
Appendages
  • appendages of the epididymis and testis have no
    known physiologic function
  • appendix testis is present in 80 of men
  • they are pedunculated structures and are capable
    of torsion
  • pain often more intense near head of epididymis
    or testis
  • isolated tender nodule often present
  • blue dot sign

50
Genitourinary Emergencies Torsion of Appendages
- Management
  • if diagnosis absolutely assured and confirmed by
    colour Doppler ultrasound (showing normal
    testicular blood flow) immediate surgery is not
    necessary
  • most appendages will calcify or degenerate over
    10-14 days and cause no harm
  • treat with bed rest, analgesia, NSAIDS
  • if any doubt about diagnosis need surgical
    exploration to exclude testicular torsion

51
Genitourinary Emergencies Torsion of the
Appendages
52
Take Home Messages
  • DKA
  • judicious fluid use 10 cc/kg bolus prn for
    shock, followed by 1.5 x maintenance
  • never use bicarb
  • probably no role for insulin bolus
  • Genitourinary Emergencies
  • if prepubescent epididymitis refer for potential
    anatomic abnormalities
  • a present cremasteric reflex makes diagnosis of
    testicular torsion far less likely
  • attempt manual detorsion while awaiting urology
    transfer
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