Zach; Vitamins

B1 Thiamine

• Deficiency
  • Early Beriberi (wet – cardiac) (dry- muscle wasting)
  • Late Wernicke- Korsakoff 
• Malnutrition, AIDS, Alcoholics
• Tx, replete 

B2 Riboflavin

• Erythematous lesions, ulceration, mucositis
• Breast fed children, skim milk, pregnant women
• Tx, replete

B3 Niacin

• Pellagra
  • 4ds
    • Diarrhea, dermatitis, dementia, death
• Alcoholics, aids, IBD, malnutrition

B5 Pantothenic Acid

• Fatigue, headache, muscle weakness, nausea
• Usually deficient with another b vitamin

B6 Pyridoxine

• Dermatologic, dental changes
• Consequence of medicines
  • INH,  valproic acid, phenytoin, hydralazine, carbamazepine
• Also decreased renal function, autoimmune disease, inborn metabolic errors

B7 Biotin

• Dermatologic and neurologic manifestation
• In pregnant women, IBD, isotretinoin, long term antiepileptics 

B9 Folate

• Megaloblastic anemia, glossitis
• Don’t confuse w B12
  • Normal MMA, elevated homocysteine
  • Elevated in both for B12
• Deficiency, pregnancy, burns, alcoholics

B12 Cobalamin

• Megaloblastic anemia, SCD, neuropathic symptoms
• Old people, vegans, IBD

C

• Scurvy
• Corkscrew hair, gingival hemorrhage, petechiae
• Malnutrition, alcoholics, pirates

Caroline; Hypoglycemia

• <70
• Symptoms generally develop <50-55
• More common in T1DM vs T2DM
• Whipple’s triad
  • Do you have low glucose
  • Do you have symptoms from low glucose
  • Do you get better with glucose
• Mechanisms against hypoglycemia
  • Glycogenolysis, gluconeogenesis
• S/Sx
  • Adrenergic; anxiety, diaphoresis, hangry, tremor
  • Neuroglycopenic; lethargy, confusion, seizures, agitation
• Most commonly in diabetics, usually overcorrection
• Nondiabetics; malnourishment, drugs/alcohol, insulinoma, critical illness, adrenal insufficiency, hypopituitary
• Workup
  • POC glucose
• Tx
  • Sugar
  • Glucagon
• D50 vs D10
  • Risk of overshooting w D50
  • D50 and be caustic
• Refractory?
  • D10 drip
  • Consider octreotide
• Has insulin pump?
  • Don’t dc pump
  • Supportive treatment 
  • Contact manufacturer to troubleshoot
• Pediatric hypoglycemia
  • Often asymptomatic until seizure
  • New onset T1DM
  • Maternal dm in neonates
  • Medicine ingestion; bb, ethanol, sulfonylurea
  • Glucose bolus 2ml/kg D10

Lyvers; pediatric endocrine

Hypoglycemia

• Causes
  • Fatty oxidation disorder
  • Insulin mediated
  • Ketotic hypoglycemia
  • Disorder of gluconeogenesis
• Other
  • Ingestion
  • Munchausen

– Obtain critical sample during hypoglycemic <50 episode

– for metabolic disorders

Fatty oxidation

• Can crump quick when glycogen depleted
• Test carnitine

Insulin mediated

Ketotic hypoglycemia

• Glycogen storage disorders
• Hormone deficiency
  • hypopit
• Idiopathic (kids grow out of this by 6-8)

Disorders of gluconeogenesis

• Glactosemia
• Fructose disorders

Tx – Rule of 50

• D10 = 5ml/kg
• D50 = 1ml/kg
• Consider steroid
• Glucagon?
  • Only helps with insulin mediated diseases bc they need preexisting hepatic stores of glycogen

Hyperglycemia

• DKA
  • New onset
    • p/w weight loss, polyuria, polydipsia, vomiting
    • Look for kussmaul  breaths
  • Glucose >200
  • pH <7.3
  • Ketones
• Tx
  • Correct acidosis, dehydration, glucose
  • Fluid resuscitation
    • Aggressive
    • 10-20 cc/kg bolus LR or NS
    • Add potassium due to shifts intracellularly
      • <3.5 = bolus
      • Defer if >5.5
        
    • Inulin 0.05 – 0.1 ug/kg
• Complications
  • Cerebral edema
  • Avoid bicarb
  • Could be from hypoperfusion from dehydration
  • Usually develops first 12hrs
  • Tx, mannitol

Shaw; Acid Base

Look at pH (primary disorder) >  check for compensation 

Respiratory

Metabolic

Metabolic acidosis is usually complicated by compensation

Winters = paCO2 = 1.5 (HCO3) + 8 +- 2

Anion gap = Na – Cl – HCO3

NAGMA = GI vs renal bicarb loss 

• Body takes in chloride

MUDPILES

Excess anion gap

• If change in anion gap > change in bicarb then too much bicarb = less acidotic
• AG – 12 + serum bicarb
  • >30  = 
  • <30 = underlying NAGMA (too  much Cl)

Use base deficit to predict resuscitation goals

VBG for people that don’t need exact pCO2, pulse ox accurate

ABG for people in shock

R acidosis – minute ventilation

R alkalosis – treat underlying cause

M alk – stop offending agent, consider CA inhibitor

M acidosis – treat underlying cause

Bicarb- need control or respirations to make sure co2 is blown off

• Otherwise benefits are primarily from Na and fluid replacemen t
• Na blocker overdose

Thomas; DKA/AKA

Gluconeogenesis/ glycogenolysis not as efficient glycolysis

Gluconeo breaks down fats and proteins

• Fat breakdown = ketones
• Happens in the liver primarily

Glyco

• No ketones
• Happens in muscle and liver

T1DM no insulin production

T2DM insulin resistance

Insulin = store

Glucagon = burn

T1DM more likely to have DKA

AKA

Wide gap acidosis in chronic drinkers

• Following a binge
• Abrupt stoppage of drinking prior to ED

Due to shift of carb metab due to malnutrition

Alcohol w no glucose

• Fasting state = glucagon secretion > gluconeogenesis (mainly lipolysis)
  • If functioning liver

S/Sx 

• N/V/abd pain
• Tachycardic, tachypnea

Labs 

• Etoh often negative
• Anion gap
• Usually w LFT abnormality

Does not need to be acidotic 

• 15% normal ph
  • compensation