Paediatric Emergencies

Question 1

DKA is an emergency as a result of what medical condition?

Answer 1

Type 1 Diabetes Mellitus (T1DM)

Question 2

What blood pH or plasma bicarbonate levels are diagnostic of DKA?

Answer 2

7.3

15mmol/L

Question 3

What blood ketone level is present in DKA?

Answer 3

beta-hyrdoxybutyrate above 3 mol/L

Question 4

What blood glucose level is present in DKA?

Answer 4

Above 11 mol/L (although can be normal)

Question 5

Describe the pathophysiology behind DKA.

Answer 5

T1DM is best seen as ‘starvation in the midst of plenty,’ where blood glucose levels are raised as it cannot be used for metabolism or stored due to an absolute deficiency of insulin (caused by autoimmune destruction of pancreatic beta cells).
This leads to a rise in counter-regulatory hormones including glucagon, cortisol, catecholamines and growth hormone.
The increase in these gluconeogenic hormones not only raises the blood glucose concentration further, but also leads to accelerated break down of adipose (fatty) tissue, resulting in rising levels of acidic ketone bodies (beta-hydroxybuturate).

Question 6

Describe the symptoms of DKA.

Answer 6

• Weight loss
• Polyuria
• Polydipsia

Question 7

What investigations should be performed if you suspect DKA?

Answer 7

1. Bedside blood glucose and ketones
2. Blood gas
3. U&Es, FBC, creatinine
4. 12-lead ECG

Question 8

What initial bolus should be given to children with DKA who are in shock?

Answer 8

20mL/kg of 0.9% sodium chloride over 15 minutes

Question 9

What initial bolus should be given to children with DKA who are not in shock?

Answer 9

10mL/kg 0.9% sodium chloride over 1 hour

Question 10

What ongoing fluids should be given to children with DKA who are in shock?

Answer 10

Up to 40mL/kg total if ongoing shock before inotropes considered. DO NOT subtract from ongoing fluid calculation (deficit + maintenance)

Question 11

What ongoing fluids should be given to children with DKA who are not in shock?

Answer 11

Calculate fluid deficit based on % dehydration. Subtract the initial 10mL/kg bolus from this and add maintenance

Question 12

For how long should insulin be delayed for after beginning IV fluid therapy?

Answer 12

1-2 hours

Question 13

Why should insulin therapy be delayed after beginning fluid therapy?

Answer 13

this has been shown to reduce the chance of cerebral oedema

Question 14

Following fluid therapy, what dose of insulin is required in patients with DKA?

Answer 14

0.05 – 0.1 units/kg/hour of a soluble insulin such as Actrapid

Question 15

When can oral fluids be commended following an episode of DKA in a child?

Answer 15

Oral fluids can be commenced once ketosis is resolving and there is no nausea of vomiting.

Question 16

When is DKA in children considered to be resolved?

Answer 16

DKA is considered to be resolved once the child is clinically well, drinking and tolerating food and the blood ketones are less than 1mmol/litre or pH is normal.

Question 17

Name some complications of DKA in children.

Answer 17

• Cerebral Oedema
• Hypokalaemia
• Aspiration pneumonia
• Hypoglycaemia

Question 18

What is the mean duration of symptoms before a child presents with DKA?

Answer 18

16.5 days

Question 19

What late sign of neurological compromise should be checked of using fundoscopy?

Answer 19

Papilloedema

Question 20

What does BRUE stand for?

Answer 20

Brief resolved unexplained event

Question 21

Define BRUE.

Answer 21

An episode that is frightening to the observer, during which a combination of the following symptoms are reported:

Apnoea
Choking or gagging
Colour change
Change in tone

Question 22

What is the most common cause of BRUE?

Answer 22

GORD

Question 23

Name some risk factors for BRUE.

Answer 23

Infants < 2 months old

Infants under 30 days old are more likely to have a serious diagnosis or another ALTE

Patients who were premature and have had multiple ALTEs are up to fourteen times more likely to have further ALTEs or serious underlying pathology

Question 24

Name some pathogens that are responsible for sepsis in children.

Answer 24

N. meningitides (meningococcus)
Streptococcus pneumoniae (pneumococcus)
Staphylococcus aureus
Group A and B Streptococcus
E. coli

Question 25

Name 4 signs of shock.

Answer 25

hypotension, tachycardia, cool peripheries, confusion