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Cerebral edema is the most feared emergent complication of pediatric diabetic ketoacidosis.A  Fortunately, it is relatively rare, but the rarity can lead to some confusion when it comes to its management.A  We recently discussed the use of mannitol and hypertonic saline for pediatric traumatic brain injury, but when should we consider these medications for the patient presenting with DKA?
This is the area that often leads to finger pointing… most often those fingers being pointed toward the Emergency Physician who was initially caring for the kid.
Generally, there is an absence of evidence that associates volume, tonicity, or rate change in serum glucose with Cerebral Edema development.
But, abnormal neurological signs are common in kids with DKA and they don’t all need therapy. Having either 1 Diagnostic Criterion, 2 Major Criteria, or 1 Major and 2 Minor criteria lead to 92% sensitivity and 96% specificity for recognition of Cerebral Edema early enough for intervention. This does lead treating an additional 5 children who don’t have Cerebral Edema for every 1 child who does. A critical MORSEL is that for every child you treat for DKA needs to have an initial thorough neuro exam including Cranial Nerves and then frequent reassessments… and document it (so your colleagues who take over care for the kid can know if there has been a change)! To assess current rates of complications of diabetic ketoacidosis (DKA), particularly cerebral edema, in a large tertiary-care pediatric hospital with a consistent management protocol. The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). To discuss the management of a rare case of cerebral edema before initiation of therapy in an adolescent with new-onset type 2 diabetes. To determine incidence, outcomes, and risk factors for pediatric cerebral edema with diabetic ketoacidosis (CEDKA) in Canada. Children who develop cerebral edema (CE) during diabetic ketoacidosis (DKA) exhibit definable signs and symptoms of neurological collapse early enough to allow intervention to prevent brain damage. Marcin JP1, Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N; American Academy of Pediatrics.
To investigate the relation between outcomes of children with diabetic ketoacidosis (DKA)-related cerebral edema and baseline clinical features and therapeutic interventions for treatment of cerebral edema.

Glaser N1, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, Kaufman F, Quayle K, Roback M, Malley R, Kuppermann N; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Cerebral edema is an uncommon but devastating complication of diabetic ketoacidosis in children. I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. Ped EM MorselsEnhance and refine your understanding of Pediatric Emergency Medicine and augment the care of pediatric patients. Also referred to as Onychomycosis, fungal nail infections are an infection underneath the surface of the nail, which can also penetrate the nail. A group of fungi called dermatophytes easily attack the nail, thriving off keratin, the nail’s protein substance.
Nail bed injuries may make the nail more susceptible to all types of infection, including fungal infection.
Clip your nails straight across so that the nail does not extend beyond the tip of the toe. Use a quality foot powder – talcum, not cornstarch – in conjunction with shoes that fit well and are made of materials that breathe. Depending on the type of infection you have, over-the-counter liquid antifungal agents, while sometimes effective, may not prevent a fungal infection from recurring. In some cases, surgical treatment is prescribed, during which the infected fungal nail is removed.
Low morbidity and mortality in children with diabetic ketoacidosis treated with isotonic fluids. The University of Arkansas for Medical Sciences Institutional Review Board approved the review of medical records.
Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis.

Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. The disease, characterized by a change in a toenail’s color, is often considered nothing more than a mere blemish, but it can present serious problems if left untreated. When the tiny organisms take hold, the nail may become thicker, yellowish-brown or darker in color, and foul smelling.
Those who suffer chronic diseases, such as diabetes, circulatory problems, or immune-deficiency conditions, are especially prone to fungal nails.
Socks made of synthetic fiber tend to “wick” away moisture faster than cotton or wool socks, especially for those with more active life styles. A topical or oral medication may need to be prescribed, and the diseased nail matter and debris removed by a process called debridement. Permanent removal of a chronically painful nail, which has not responded to any other treatment, permits the fungal infection to be cured, and prevents the return of a deformed nail.
A previously healthy obese adolescent female suffered diabetic ketoacidosis (DKA)-related cerebral edema before initiation of therapy. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema.
The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Debris may collect beneath the nail plate, white marks frequently appear on the nail plate, and the infection is capable of spreading to other toenails, the skin, or even the fingernails.

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