Altered Consciousness Flashcards
List 3 causes for tachycardia in a teenage patient
- Hypovolaemic shock
- Use of medications e.g. salbutamol
- Anxiety
- Cardiac arrhythmia (secondary to electrolyte imbalance)
- Co-existing endocrine conditions e.g. hyperthyroidism
List 4 causes for abnormal respiration patterns in teenage patients
- Endocrine - DKA (Kussmaul breathing?)
- Asthma exacerbation
- Chest infection
- Cardiac disease
- Metabolic - acidosis or alkalosis compensation?
- Anxiety
What may cause agitation in a child presenting acutely unwell?
- Hypoglycaemia - due to vomiting
- Exhaustion - IWOB
- Hypocapnia - secondary to hyperventilation
- Cerebral oedema
- DKA
- Encephalopathic due to infection (viral or bacterial) or high ammonia
What is diabetic ketoacidosis (DKA) and what is its pathophysiology?
- A consistently high blood glucose can lead to DKA.
- This happens when there is a severe lack of insulin, meaning intracellular glucose cannot be used for energy so the body begins to break down other body tissues as an emergency energy source.
- Ketones are a byproduct of this process.
- Ketones are poisonous and if they are left for too long the body becomes acidic.
DKA is a life-threatening emergency! When is it most common for someone to have DKA?
- At diagnosis - many do not realise they have T1DM until they become very unwell with DKA
- When they are ill (viral infection etc)
- During a growth spurt/puberty
- When insulin has been omitted
- DKA usually develops over 24 hours, but can be faster in young children
When would you take a capillary blood glucose measurement from a child/young person?
If they present with increased thirst, polyuria, recent unexplained weight loss or excessive tiredness and they DO NOT know they have diabetes with any of the following;
- N+V
- Abdominal pain
- Hyperventilation
- Dehydration
- Reduced level of consciousness
At what level plasma glucose, in a patient with or without diabetes, would you suspect DKA (if they have signs suggestive of DKA)?
> 11 mmol/L
What signs would lead you to suspect DKA in a child with known diabetes?
- N+V
- Abdominal pain
- Hyperventilation
- Dehydration
- Reduced level of consciousness
What would you test in a child with known diabetes if you were suspecting DKA?
Blood ketones
Blood glucose
What measurements would be taken from a child who has been referred to hospital with suspected DKA?
- Capillary blood glucose
- Capillary blood ketones (use to be urinary but this is no longer deemed accurate)
- Capillary/venous pH and bicarb
When can you diagnose DKA in a child/young person with diabetes?
- Acidosis - Blood pH <7.3 or plasma bicarbonate below 18 mmol/l
- Ketonaemia - blood beta-hydroxybutyrate >3
- If blood pH <7.1 then this is SEVERE DKA
What are the causes of Kussmaul breathing?
DKA and Hyperpnoea is common
K - Ketones U - Uraemia S - Sepsis S - Salicylates M - Methanol A - Aldehydes U L - Lactic acid/acidosis
What is Kussumaul breathing?
Deep and laboured breathing pattern, often associated with severe metabolic acidosis.
When can a child with DKA be given IV fluids and IV insulin?
- If they are not alert
- If they are nauseated or vomiting
- If they are clinically dehydrated
What is the warning from NICE about giving oral fluids to a child receiving IV fluids with DKA?
DO NOT give oral fluids to a child/young person receiving IV fluids for DKA unless their ketosis is resolving, they are alert and have no N+V
What percentage fluid deficient should you assume in a child with; mild to moderate DKA (blood pH 7.1
5% deficient
What percentage fluid deficient should you assume in a child with; severe DKA (blood pH 7.1>)?
10% deficient
How do you calculate the total fluid requirement of a child with DKA for the first 48 hours?
Estimated fluid replacement + Fluid maintenance requirement
How do we calculate the maintenance fluid requirement in children with DKA?
Reduced volume rules must be used;
- If they weigh <10kg then give 2ml/kg/hour
- If they weigh between 10 and 40kg then give 1ml/kg/hour
- If they weigh >40kg then give a fixed value of 40ml/hour
Why should the volume of fluids given to a patient with DKA be reduced compared to the non-DKA dehydrated child?
Larger fluid volumes are linked with an increased risk of cerebral oedema this is why rehydration is carried out slowly over the first 48 hours
Which fluid should be used in DKA patients and why?
0.9% NaCl WITHOUT glucose unless their glucose is below 14mmol/l.
This is because they will already have hyperglycaemia so glucose will be harmful not helpful
How long after starting IV fluids should IV insulin be started?
1-2 hours after IV fluid therapy has commenced
How much IV insulin infusion should be given per hour to a patient with DKA?
0.05-0.1 units/kg/hour
What should be monitored and recorded in the notes, at least hourly, in children/YA with DKA?
- Capillary blood glucose
- Ketones
- Vital signs (HR, RR, BP, Temp)
- Fluid balance
- Fluid input and output charts
- Level of consciousness
How often should we record level of consciousness in children under 2 years of age and why?
Every 30 minutes
They are at increased risk of cerebral oedema
What further investigation should be monitored continuously in children/YA who are receiving IV therapy for their DKA?
A continuous ECG to detect any signs of hypokalaemia
2 hours after commencing treatment (and every 4 hours thereafter) what blood measurements should be recorded in those with DKA?
- Blood glucose
2. Blood gas - pH, pCO2, Na, K, Urea
How often should a clinician review a child/YA with DKA face-to-face?
4 hourly at least
What are the most common complications of DKA?
- Cerebral oedema
- Hypokalaemia
- VTE
What are the signs/symptoms of Cerebral oedema in a DKA patient?
- Headache
- Agitation
- Irritable
- Unexpected bradycardia and hypertension
How would you treat cerebral oedema in DKA?
Mannitol (20% 0.5-1g/kg over 10-15 minutes)
