Diabetic ketoalkalosis in children and adults.

OBJECTIVES: Diabetic ketoacidosis (DKA) with metabolic alkalosis (diabetic ketoalkalosis [DKALK]) in adults has been described in the literature, but not in the pediatric population. The discordance in the change in the anion gap (AG) and the bicarbonate is depicted by an elevated delta ratio (DR; rise in AG/drop in bicarbonate), which is normally approximately 1. The primary aim of this study was to determine whether DKALK occurs in the pediatric population, as has been seen previously in the adult population. The secondary aim was to determine the factors that may be associated with DKALK. METHODS: A retrospective analysis of adult and pediatric cases with a primary or secondary discharge diagnosis of DKA between May 2008 and August 2010 at a large urban hospital was performed. DKALK was assumed to be present if the DR was >1.2 or in cases of elevated bicarbonate. RESULTS: Of 190 DKA cases, 91 were children, with 21% fulfilling the criterion for DKALK. There were 99 adult cases, 35% of which fulfilled the criterion for DKALK. Our final logistic model revealed that among patients with a discharge diagnosis of DKA, male patients, patients with a history of renal failure, and patients presenting with abdominal findings on physical examination were at greater odds of having a concomitant metabolic alkalosis. CONCLUSIONS: Although DKALK has been described in adults, it can occur in a significant number of children presenting with DKA. The recognition of DKA can be obscured in such situations unless the AG and DR are calculated because the pH and bicarbonate may be near normal or even elevated. In addition to having interesting biochemical features as a complex acid-base disorder, DKALK can pose diagnostic and/or therapeutic challenges.

Alternate light sources in sexual assault examinations: an evidence-based practice project.

The ability of sexual assault nurse examiners to correctly identify and collect DNA evidence improves patient outcomes and prosecution rates. The purpose of this paper is to present findings from a collaborative evidence-based practice (EBP) project between forensic nurses and baccalaureate nursing students. The goal of the project was to determine best practice using an alternate light source (ALS) to identify trace DNA evidence in sexual assault forensic examinations. Using the Johns Hopkins Nursing Evidence-based Practice model, the team searched several databases to summarize the limited amount of evidence available regarding this topic. Recommendations from the EBP project include: elimination of the Wood's lamp in sexual assault examinations; use of an ALS that provides appropriate wavelengths to detect DNA; education of forensic nurses about the advantages and limitations of an ALS; and additional research related to use of an ALS. By participating in similar collaborative efforts, practicing forensic nurses have the opportunity to collaborate with local colleges and universities to make complex projects more manageable while fulfilling the International Association of Forensic Nurses vision for ethical practice.

CSI: New @ York: development of forensic evidence collection guidelines for the emergency department.

Emergency department (ED) nurses care for victims of trauma almost daily. Although preservation of evidence is crucial, the ED is chaotic when a trauma patient arrives and staff members must do everything possible to save the patient's life. However, an integral responsibility of the staff nurse is collection and preservation of forensic evidence. This article provides insight into the process undertaken by a multidisciplinary team to develop a set of evidence-based guidelines for forensic evidence collection. The team compiled evidence from more than 20 articles and consultations with law enforcement officials and forensic experts. This information was used to develop a set of guidelines for forensic evidence collection in the ED or operating room. Staff educational needs presented some challenges. Training was designed to specifically address the roles of three major groups of staff: patient representatives and emergency and trauma nurses. Educational topics included evidence recognition, handling of clothing, gross/trace evidence, documentation, packaging of evidence, and use of the "chain-of-evidence" form. Practice modifications included development of a new "chain-of-evidence" form, a forensic cart in the operating room, and use of a collapsible plastic box for collection of clothing in the ED.