Paeds Flashcards
How can you diagnose DKA in children?
- acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 15 mmol/litre) and
- ketonaemia (indicated by blood beta-hydroxybutyrate above 3 mmol/litre)
Blood glucose levels are generally high (above 11 mmol/l) but children and young people with known
diabetes may develop DKA with normal blood glucose levels.
What are the different severities of paediatric DKA?
Children and young people with a pH 7.2- 7.29 &/or bicarb < 15 have MILD DKA
Children and young people with a pH less than 7.1-7.19 &/or bicarb < 10 have
MODERATE DKA
Children and young people with a pH less than 7.1 &/or bicarb < 5 have
SEVERE DKA
How would you manage a child with DKA?
A-E dealing with each issue as it arises
A-B - patent and put 100% 02 on
C
- All children and young people with mild, moderate or severe DKA who are not shocked and are felt to require IV fluids should receive a 10 ml/kg 0.9% sodium chloride bolus over 30 minutes.
-Patients with shock require appropriate restoration of their circulation and circulatory volume. SHOCKED patients should receive a 10 ml/kg bolus over 15 minutes
- Following the initial 10 ml/kg bolus shocked patients should be reassessed and further boluses of 10 ml/kg may be given if required to restore adequate circulation up to a total of 40 ml/kg at which stage inotropes should be considered
How should maintenance fluid be calculated in DKA?
Once circulating blood volume has been restored and the child adequately resuscitated,
calculate fluid requirements as follows: Requirement = Deficit + Maintenance
Fluid Deficit
It is not possible to accurately clinically assess the degree of dehydration to work out the deficit. Clinical methods are unreliable. Estimation of the fluid deficit should be based on the initial blood pH. The fluid deficit should be replaced over 48 hours alongside maintenance fluids.
-Assume a 5% fluid deficit in children and young people in mild DKA
(indicated by a blood pH 7.2-7.29 &/or bicarbonate <15)
-Assume a 5% fluid deficit in children and young people in moderate DKA
(indicated by a blood pH of 7.1- 7.19 &/or bicarbonate <10)
-Assume a 10% fluid deficit in children and young people in severe DKA
(indicated by a blood pH <7.1 &/or bicarbonate <5)
Resuscitation fluid – The volume of any fluid boluses given for resuscitation in children with shock should NOT be subtracted from the estimated fluid deficit.
The initial 10ml/kg bolus given to all non-shocked patients requiring IV fluids SHOULD be subtracted from total calculated fluid deficit.
The deficit should be replaced over 48 hours alongside appropriate maintenance fluids
Maintenance fluid
Maintenance fluid volumes should be calculated using the Holliday – Segar formula (the traditional method of calculating fluid volume in children in the UK) – 100 ml/kg/day for the first 10 kg body weight, plus 50 ml/kg/day for 10 to 20 kg and 20 ml/kg/day for each additional kilogram above 20 kg.
Maintenance Fluid:
* 100 ml/kg/day for the first 10 kg of body weight
* 50 ml/kg/day for the next 10 to 20 kg
* 20 ml/kg/day for each additional kilogram above 20 kg
How should potassium and insulin be managed in paediatric DKA?
- Ensure all fluid, except bolus fluid contains potassium as hypokalaemia develops.
- Where Potassium is above the upper limit of the normal range at presentation it is recommended that Potassium is only added to Intravenous fluids after the patient has passed urine (to confirm they are not becoming anuric), gives a history of having recently passed urine, or after the Potassium has fallen to within the upper limit of the normal range (which it typically will have done after the initial 10ml/kg bolus has been given)
- If Potassium is low at presentation (<3.0 mmol/l) then insulin administration should be deferred until
Potassium is >3.0mmol/l - Once rehydration fluids and potassium are running, blood glucose levels will start to fall. There is some evidence that cerebral oedema is more likely if insulin is started early. Do not give bolus doses of intravenous insulin.
- Therefore start an intravenous insulin infusion 1-2 hours after beginning intravenous fluid therapy.
- Use a soluble insulin infusion at a dosage between 0.05 and 0.1 units/kg/hour.
What are the duct dependant lesions? Can you give some examples?
Duct-dependent systemic lesions: systemic circulation is dependent on right to left flow
through the ductus arteriosus. Closure results in cardiovascular collapse.
Duct-dependent pulmonary lesions: pulmonary blood flow is dependent on left to right
shunting from the aorta to the pulmonary arteries through the ductus.
Duct dependent systemic circulation - Hypoplastic left heart syndrome, Critical aortic stenosis, Coarctation of the aorta
Duct-dependent pulmonary lesions - Pulmonary atresia, Critical pulmonary stenosis, Tricuspid atresia, Severe tetralogy of Fallot
How you manage a neonate with a suspected CHD duct dependant lesion?
Airway and breathing
Intubation if in respiratory distress or shocked (or apnoeic due to prostaglandin).
Monitor pre-and post ductal saturations (right finger and either foot).
Aim for saturations 75-85% (over-oxygenation reduces pulmonary vascular resistance
leading to increased pulmonary blood flow and reduced systemic flow).
Circulation
2x venous access & bloods including blood cultures and blood gas.
4 limb blood pressures.
Fluid bolus 10ml/kg up to max 30ml/kg.
Consider dopamine if resistant shock.
Prostaglandin - keeps the closing duct open, occasionally reopens a closed duct.
Aim for palpable pulses, resolution of cyanosis and resolution of metabolic acidosis.
Consider other causes - eg antibiotics for sepsis.
Options for prostaglandins include:
Dinoprostone (prostaglandin E2) 5 nanograms/kg/min titrated to 100/kg/min.
Adverse effects include: apnoea, bradycardia, severe hypotension & hyperthermia.
In congenital heart disease, what is the hyperoxia test?
Hyperoxia test: helps to distinguish between right-to-left shunt and other causes of neonatal illness like sepsis. Administer 100% O2 for 10 minutes. Persistently low saturations supports CHD.
What is child abuse?
Abuse is the suspected or actual harm inflicted by neglect, physical, sexual or emotional mistreatment
Are you allowed to break confidentiality with regards to chid abuse?
It is good practice to ask for the patient’s consent before sharing
confidential information in order to protect other people. This may
not be practicable or, if it is believed that doing so may jeopardise
the safety of the child or young person, appropriate.
If you suspect a child is a victim of abuse, what steps should you take?
You must inform the relevant authority promptly and securely. If the child or young person is not in immediate danger, local safeguarding procedures should be followed. However, if the child or young person is in immediate danger, the police should be contacted.
● Share your concerns and get advice from the local designated professional or lead clinician for child protection.
● Share relevant information about the child protection concerns. GMC guidance states you should provide information about both of the following:
a) the identities of the child or young person, their parents and any other person who may pose a risk to them.
b) the reasons for your concerns and any relevant information about their parents or carers.
● Inform your patient You should discuss with your patient the information shared, with whom and the reasons unless doing so would put the child or young person at increased risk.
● Follow up your concerns.If you believe your concerns have not been acted upon properly escalate to the next level of authority.
● Make a clear, contemporaneous record. Record your concerns and the details of any actions taken.
What are some of the risk factors for child abuse?
Child-related factors
-Chronic disability/illness
-Prematurity/low birth weight
-Unplanned/unwanted children
-Children with physical or learning disabilities/behavioural problems
Parental factors
-Step-parents
-Teenage parents
-Substance abuse
-Parents abused as a child
-Disabled parents
-Mental health problems
Family factors
-Single-parent families
-Domestic violence
Social factors
-Unemployment
-Poverty
-Social isolation
Can you give some examples of possible NAI?
Physical
- burns
- scalds
- Bruises
- Poisoning
- Bite marks
- Abdominal trauma
- Head trauma
- Slap marks
Sexual
- Anogenital injuries
- STIs
- Inappropriate behaviour
When should you suspect a NAI in intracranial injuries?
Suspect NAI where intracranial injury presents:
- Without an adequate explanation
- In a child under 3 years old
In the presence of: - Retinal haemorrhage
- Rib or long bone fractures
- Other associated injuries
-With multiple subdural haemorrhages
