Paeds 6B Flashcards
Which biochemical parameters should be measured in a patient with DKA?
pH and pCO2 Plasma sodium, potassium, urea and creatinine Plasma bicarbonate Blood glucose Blood ketones
Outline how the fluid deficit in DKA is estimated.
5% fluid deficit = mild-moderate DKA (> 7.1)
10% fluid deficit = severe DKA (< 7.1)
Outline how maintenance fluid requirements are calculated in patients with DKA.
< 10 kg = 2 ml/kg/hour
10-40 = 1 ml/kg/hour
40+ = 40 ml/hour
These are lower than standard maintenance fluid calculations because of the risk of cerebral oedema
Which fluids should be given when rehydrating patients with DKA?
0.9% saline ONLY until plasma glucose < 14 mmol/L
Then change to 0.9% saline + 5% dextrose
Rehydrate over 48 hours
Consider switching to oral fluids once the child is alert, ketosis is resolving and they can tolerate oral fluids
What should all fluids administered to patients with DKA contain?
40 mmol/L potassium chloride (unless renal failure)
Describe how insulin therapy should be given in DKA.
Start IV insulin infusion 1-2 hours after beginning IV fluid therapy
Use soluble insulin at 0.05-0.1 units/kg/hour (disconnect insulin pump if present)
Consider increasing insulin dose if no reduction in blood ketones after 6-8 hours
When can SC insulin be started in a patient with DKA?
Consider if ketosis is resolving, child is alert and can tolerate oral fluids
Start SC insulin at least 30 mins before stopping IV insulin
If using an insulin pump, start the pump at least 60 mins before IV insulin is stopped
How should a child be monitored whilst receiving treatment for DKA?
Measure at least HOURLY
• Capillary blood glucose
• Vital signs (HR, BP, Temp, RR)
• Fluid balance with fluid input and output charts
• Level of consciousness (using modified GCS)
NOTE: if severe DKA or < 2 years, monitor every 30 mins
What else should be monitored in a patient receiving IV therapy for DKA?
Continuous ECG (detect hypokaleemia)
NOTE: if K+ < 3 mmol/L, consider temporarily stopping the insulin and discuss with paediatric critical care
What should be measured 2 hours after starting treatment for DKA and at least every 4 hours afterwards?
Glucose (laboratory)
Blood pH and CO2
Plasma sodium, potassium and urea
Beta-hydroxybutyrate
NOTE: every 4 hours, review clinical status, blood results, ECG trace and fluid balance
List some clinical features of cerebral oedema.
Headache
Agitation or irritability
Unexpected fall in heart rate
Increased blood pressure
How is cerebral oedema resulting from DKA treatment managed?
IV mannitol or hypertonic sodium chloride
How is congenital hypothyroidism treated?
Start thyroxine treatment within 2-3 weeks of age and continue throughout life
With adequate treatment, intelligence and development should be normal
How is acute symptomatic hypocalcaemia managed?
IV calcium gluconate
NOTE: chronic is managed with oral calcium and high dose vitamin D analogues
Outline the aspects of managing congenital adrenal hyperplasia.
Corrective surgery (usually at puberty)
Life-long glucocorticoids
Mineralocorticoids (if salt loss)
Monitor growth, skeletal maturity, plasma androgens and 17a-hydroxyprogesterone levels
Outline the management of an Addisonian crisis.
IV hydrocortisone
IV saline
IV glucose
Fludrocortisone may be needed
How is androgen insensitivity syndrome managed?
Investigation: karyotype
Bilateral orchidectomy (risk of testicular cancer) Oestrogen therapy
For how long should children with measles or rubella be excluded from school?
4 days from the onset of the rash
Which investigations should be requested in a patient with suspected non-accidental injury?
Skeletal survey
CT head scan
Bloods and bone profile (rule out leukaemia, ITP)
Fundoscopy (retinal haemorrhages)
Who should be contacted in cases of suspected non-accidental injury?
Senior colleagues
Named doctor for child protection
Social services
Consider contacting the police (Child Abuse Investigation Team)
Consider contacting Mutli-Agency Safeguarding Hub (MASH)
What are the differences between diplegic, hemiplegic and quadriplegic cerebral palsy?
Diplegic: both legs and arms are involved, legs are affected more than arms, associated with periventricular leukomalacia and preterm babies, do NOT tend to have severe learning difficulties/epilepsy
Hemiplegic: affects one side of the body, arms more than legs
Quadriplegic: most severe form, all four limbs are severely affected, associated with learning difficulties, epilepsy and swallowing problems
What are some features of innocent murmurs?
Asymptomatic
Systolic
Louder during fever and exercise
Vary with respiration and posture
What counts as precocious and delayed puberty?
Precocious - Girls < 8, Boys < 9
Delayed - Girls > 13, Boys > 14
Which investigations might be used for delayed puberty?
Pubertal staging (Tanner) Accurate height and weight measurements Bone age Gonadotrophin levels Visual field examination CT/MRI head scan Karyotype
Which scoring system is used to assess the severity of croup?
Westley croup score
