Paeds 6B

Question 1

Which biochemical parameters should be measured in a patient with DKA?

Answer 1

pH and pCO2 
Plasma sodium, potassium, urea and creatinine 
Plasma bicarbonate 
Blood glucose 
Blood ketones

Question 2

Outline how the fluid deficit in DKA is estimated.

Answer 2

5% fluid deficit = mild-moderate DKA (> 7.1)

10% fluid deficit = severe DKA (< 7.1)

Question 3

Outline how maintenance fluid requirements are calculated in patients with DKA.

Answer 3

< 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

Question 4

Which fluids should be given when rehydrating patients with DKA?

Answer 4

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

Question 5

What should all fluids administered to patients with DKA contain?

Answer 5

40 mmol/L potassium chloride (unless renal failure)

Question 6

Describe how insulin therapy should be given in DKA.

Answer 6

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

Question 7

When can SC insulin be started in a patient with DKA?

Answer 7

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

Question 8

How should a child be monitored whilst receiving treatment for DKA?

Answer 8

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

Question 9

What else should be monitored in a patient receiving IV therapy for DKA?

Answer 9

Continuous ECG (detect hypokaleemia)

NOTE: if K+ < 3 mmol/L, consider temporarily stopping the insulin and discuss with paediatric critical care

Question 10

What should be measured 2 hours after starting treatment for DKA and at least every 4 hours afterwards?

Answer 10

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

Question 11

List some clinical features of cerebral oedema.

Answer 11

Headache
Agitation or irritability
Unexpected fall in heart rate
Increased blood pressure

Question 12

How is cerebral oedema resulting from DKA treatment managed?

Answer 12

IV mannitol or hypertonic sodium chloride

Question 13

How is congenital hypothyroidism treated?

Answer 13

Start thyroxine treatment within 2-3 weeks of age and continue throughout life
With adequate treatment, intelligence and development should be normal

Question 14

How is acute symptomatic hypocalcaemia managed?

Answer 14

IV calcium gluconate

NOTE: chronic is managed with oral calcium and high dose vitamin D analogues

Question 15

Outline the aspects of managing congenital adrenal hyperplasia.

Answer 15

Corrective surgery (usually at puberty)
Life-long glucocorticoids
Mineralocorticoids (if salt loss)
Monitor growth, skeletal maturity, plasma androgens and 17a-hydroxyprogesterone levels

Question 16

Outline the management of an Addisonian crisis.

Answer 16

IV hydrocortisone
IV saline
IV glucose
Fludrocortisone may be needed

Question 17

How is androgen insensitivity syndrome managed?

Answer 17

Investigation: karyotype

Bilateral orchidectomy (risk of testicular cancer)
Oestrogen therapy

Question 18

For how long should children with measles or rubella be excluded from school?

Answer 18

4 days from the onset of the rash

Question 19

Which investigations should be requested in a patient with suspected non-accidental injury?

Answer 19

Skeletal survey
CT head scan
Bloods and bone profile (rule out leukaemia, ITP)
Fundoscopy (retinal haemorrhages)

Question 20

Who should be contacted in cases of suspected non-accidental injury?

Answer 20

Senior colleagues
Named doctor for child protection
Social services
Consider contacting the police (Child Abuse Investigation Team)
Consider contacting Mutli-Agency Safeguarding Hub (MASH)

Question 21

What are the differences between diplegic, hemiplegic and quadriplegic cerebral palsy?

Answer 21

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

Question 22

What are some features of innocent murmurs?

Answer 22

Asymptomatic
Systolic
Louder during fever and exercise
Vary with respiration and posture

Question 23

What counts as precocious and delayed puberty?

Answer 23

Precocious - Girls < 8, Boys < 9

Delayed - Girls > 13, Boys > 14

Question 24

Which investigations might be used for delayed puberty?

Answer 24

Pubertal staging (Tanner) 
Accurate height and weight measurements 
Bone age 
Gonadotrophin levels
Visual field examination 
CT/MRI head scan 
Karyotype

Question 25

Which scoring system is used to assess the severity of croup?

Answer 25

Westley croup score