DKA

Question 1

A 12 year old boy presents to ED with 2 days of diarrhoea and vomiting. His BSL is 24mmol/L and blood ketones are 3. How will you assess and manage him?

Answer 1

Impression;
In patient of this age demographic, likely is a presentation of DKA, meeting 2/3 diagnostic criteria based on stem. Complications are of raised ICP and cerebral oedema with concomitant complications, so want to emergently treat and manage to prevent these from occurring.

Other causes of ketosis;
- lactic acidosis
- starvation ketosis
- aspirin, ethylene and propylene glycol

Is a medical emergency, would call for senior assistance early before beginning A to E assessment, initiating fluid resus and starting insulin infusion. Assess for neuro complications and treat emergently with mannitol (under senior guidance)

Question 2

DKA - Assessment

Answer 2

Assessment;
A - Patent, maintaining, suction for vomitus, L lateral position if ongoing, provide antiemetics
B - RR/SP02 monitoring. Supplemental 02 as required
C - BP/HR monitoring. IVC for initial bloods. Repeat VBG.
o NS fluid resus with bolus and ongoing infusion
o Insulin infusion, add dextrose once BSL starts to fall (prevent hypoglycaemia)
o regular assessment of acidosis, BSL and ketones
D - GCS, assess for evidence of raised ICP - vomiting, obtunded, pupils, headache, cushings response - administer Mannitol under senior guidance if suspicious of cerebral oedema

Question 3

DKA - History

Answer 3

History;
- Sx: Polydipsia, polyuria, polyphagia, abdo pain, nausea, vomiting, etc
- Triggers: first presentation, medication non-adherence, infection/other stressor
- Complications: dehydration sx
- Fam history: autoimmune diseases, diabetes,
- Paeds history, development, growth, vaccinations

Question 4

DKA - Examination

Answer 4

Examination
- General appearance + vitals
- Hydration status
- neurological examination: features of cerebral oedema (cushings response, etc)
- systems review

Question 5

DKA - Investigations

Answer 5

Investigations
Diagnostic
- VBG: BSL>11, Ketonaemia/ketonuria, pH<7.3

• Bedside: ECG, UA
• Bloods: FBC, UEC, LFT, CRP/ESR
• Imaging:

Question 6

DKA - Management

Answer 6

Management
As per A to E in acute setting
- fluids (10mL/kg)
- insulin dextrose infusion - aim to keep BSL between 5-10mmol/L
- add potassium replacement
- identify and treat precipitating cause if relevant
- monitor EUCs for other electrolyte derangements and correct

Supportive
- paeds endocrine referral
- diabetes educator
- patient education and counselling for medication adherence
- electrolyte replacement/balancing