DKA

Question 1

A 6 year old boy presents to the ED with vomiting and loose stools. On examination, you noticed that he had dry mucus membranes, sunken eyes and a ‘fruity’ smelling breath.

Answer 1

Impression
Given the evidence of dehydration, loose stools and likely ketotic fetor, provisionally I think this is a presentation of diabetic ketoacidosis, which is a metabolic insult that occurs in young children on a background of type 1 diabetes mellitus and presents with a triad of hyperglycaemia, ketosis and metabolic acidosis. Common triggers for DKA in paeds includes first presentation, other illness (infection), and inadequate insulin administration. Of particular note, cerebral oedema is the key life-threatening complication to avert in DKA presentations, as well as hyperglycaemia and hypokalaemia

Other Ddx to consider:
- sepsis
- anaphylaxis
- dehydration
- other infective: gastroenteritis,
- other causes of ketosis:

Goals
- correct dehydration and hypovolaemia, reverse ketosis, acidosis and hyperglycaemia whilst preventing important complications of DKA and its management
- identify and treat any precipitating causes

Question 2

DKA - assessment

Answer 2

Assessment
Biochemical requirements for diagnosis
- serum BSL >11mmol/L
- venous pH <7.3
- ketonaemia/ketonuria

An acute presentation of DKA is a medical emergency, and I would call for senior help and begin an A to E assessment initiating emergent management

A - patent, maintaining (adjuncts/intubation pending GCS)
B - RR, SP02, supplemental as required, kussmaul’s resps
C - IVC access, ECG and VBG (pH, K, ketones), administer fluid bolus and slowly correct electrolyte derangements, insulin-dextrose infusion
D - GCS

Would conduct targeted Hx/Ex/Ix concurrently to emergent assessment and management.

Question 3

DKA - History

Answer 3

History
- Sx: polyuria, polydipsia, abdo pain, N/V/D, fatigue, lethargy. recent viral illnesses
- Infective: fever, myalgia, rigors
- PMHx: T1DM diagnosis, fam history,
- Medications, allergies,
- Paeds hx, development, growth

Question 4

DKA - Examination

Answer 4

Examination
- A to E assessment, GCS/AVPU
- General appearance + vitals
- hydration status assessment

Question 5

DKA - Investigations

Answer 5

Key/diagnostic
- serum BSL (>11)
- Ketonaemia/ketonuria
- VBG (pH<7.3)

• bedside: urinalysis, ECG
• labs: VBG (at POC), CRP/ESR, FBC, UEC, serum ketones
• imaging

Question 6

DKA - Management

Answer 6

Management
Considerations aside from emergent AtoE assessment;
- paediatric ICU admission/transfer/retrieval by NETS
- involve senior colleagues early

Definitive
- fluid hydration (NS)
- insulin +/- dextrose infusion, +/- potassium
- administer mannitol IMMEDIATELY if any indication of cerebral oedema, do not wait for cerebral imaging, however would be administered by consultant on-call
- signs of cerebral oedema
o irritability
o vomiting
o LOC
o thermal instability
o cushings triad (Brady, hypertension,

Supportive
- regular monitoring of BSL, ketones and pH
- regular neurological obs, regular
- head up, limit fluid rate if concerns re cerebral oedema

Ongoing
- optimise diabetes management
- paeds endocrine referral