Pediatric DKA Flashcards
What are the first 5 interventions that should be performed in an ill-appearing pt?
Oxygen Cardiac and respiratory monitor Pulse ox IV access Consider EKG/CXR
What two tests should be ordered right away in an ill-appearing patient?
Accucheck and UA
Always be leery of vomiting (with/without) diarrhea!
WITHOUT
A diagnosis of DKA cannot be made without the presence of ____ and ___ (hint: lab findings)
hyperglycemia and acidosis
Hyperglycemia is when blood glucose is _____ mg/dL and Acidosis is when venous pH is ____ and/or
bicarbonate is ____ mmol/L
hyperglycemia > 200
venous pH < 7.30
bicarb < 15
In terms of venous pH and bicarb levels:
Mild acidosis : pH ____, bicarbonate ____ mmol/L
Moderate acidosis : pH ____, bicarbonate ____ mmol/L
Severe acidosis: pH ____, bicarbonate ____ mmol/L
Mild acidosis : pH < 7.30, bicarbonate < 15 mmol/L
Moderate acidosis : pH < 7.20, bicarbonate < 10 mmol/L
Severe acidosis: pH < 7.10, bicarbonate < 5 mmol/L
During DKA, the liver makes more and more _____ and breaks down ____ b/c the cells are telling it that they are “starving”
glucose; glycogen
Fat breakdown results in production of _______
ketoacids
Dehydration and poor perfusion leads to _________
lactic acidosis
Why do children with DKA take those long deep breaths? What are those breaths called?
“Kussmaul respirations”, to “blow off” more CO2 in an attempt to compensate for metabolic acidosis
What is polyuria?
increased volume and frequency of urination
Which of the following are sx of acidosis? Hyperglycemia?
Weight loss Muscle cramps Polyuria Altered mental status Vomiting Shortness of breath Headache New urinary incontinence Polydipsia Abdominal pain Confusion
Acidosis: Abdominal pain Vomiting Shortness of breath Headache Confusion Altered mental status
Hyperglycemia: Polyuria Polydipsia New urinary incontinence Weight loss Muscle cramps
What are possible PE findings associated with DKA?
Kussmaul respirations
Dehydration (sunken eyes, DMM) signs of shock
Tachycardia
Delayed capillary refill
Abdominal tenderness (non focal or epigastric)
Why do kids with DKA get dehydrated?
Osmotic diuresis
Kidneys normally reabsorb glucose and water
In uncontrolled diabetes, the kidneys are overwhelmed by excess glucose
The excess glucose keeps water in the renal tubules
This causes increased urination (polyuria) and dehydration
Vomiting can also contribute!
Why do kids with DKA have electrolyte imbalances?
Ketoacids bind Na+ and K+ and they are excreted in the urine
Hyponatremia and hypokalemia result
_____ is the most common cause of diabetes related death in childhood, with children ____ y/o at the greatest risk
DKA (duh); <5 y/o
What are the 4 “I”s of DKA?
Insulin (lack)
Indiscretion (of diet)
Infection
Impregnation (or other stressors)
When rehydrating a pt with DKA, you want to administer fluids (quickly/slowly). Why?
Slowly, to prevent fluid overload and cerebral edema
Consider ordering an EKG to check for ______ secondary to electrolyte imbalances
arrhythmias
As part of managing DKA in the ED, how often should you reassess the following? Accucheck every \_\_\_\_\_ VBG every \_\_\_\_ BMP every \_\_\_\_\_ Neurologic checks every \_\_\_\_\_
Accucheck every 1 hr
VBG every 1-2 hr
BMP every 4 hr
Neurologic checks every hr
During rehydration of a pt with DKA, why may some institutions prefer using LR over NS?
LR does not have negatively charged Cl
After rehydration of a pt with DKA, what is the next step in tx?
Insulin
Do you administer an insulin bolus to all pts with DKA? Why/why not?
No insulin bolus in children! (may increase risk of cerebral edema)
Ideally do not want glucose to fall more than ____ mg/dl per hour
100
Switch to D5NS when glucose is ____ mg/dL
Why?
<300
Do not want to precipitate an episode of hypoglycemia!
There is almost NO clinical benefit of _____ therapy in DKA as it can cause paradoxical CNS acidosis, worsen hypokalemia when administered rapidly, or increase hepatic ketone production.
Bicarb
Insulin administration stops further _____ synthesis
ketoacid
IV hydration improves ____ ____ and ____ ____
and reverses _____ _____
tissue perfusion and renal function; lactic acidosis
Total body ____ is depleted in DKA, as it is excreted in the urine when it binds to the ketoacids. You should administer _____ even if levels appear normal bc once you start giving insulin and correcting the acidosis, this drives the _____ into the cells, lowering the pt’s ____ levels further. (same answer for all blanks)
Potassium
What is the most serious complication and most important cause of mortality in children with DKA?
cerebral edema
Cerebral edema accounts for ___-___% of all deaths from DKA
60-90%
Signs and sx of cerebral edema include…
Headache
Gradual decrease in LOC
Slowing of HR inappropriately with increase in BP
Change in pupils
Cushing’s triad of cerebral edema….
Bradycardia, increase BP, irregular respirations
T/F Cerebral edema can be present before treatment of DKA has begun
True
Potential complications of DKA include…
Hyponatremia Hypokalemia Acute renal failure Rhabdomyolysis Rarely ARDS and pulmonary edema
A 14 year old F with type I diabetes is brought in by her mother for vomiting and malaise. Her mother reports she has a history of poor compliance with her insulin and she is not sure if she has been using her insulin. On exam, she is alert with dry lips with a HR of 120 and a BP of 110/60. Her bedside glucose is 450 mg/dl and her VBG shows a pH of 7.1. Your first step in management is which of the following:
A. Insulin bolus of 0.1 units/kg
B. Normal saline or LR bolus 20 ml/kg over 1 hour
C. Sodium bicarbonate 2 meq/kg
D. Mannitol 2 g/kg IV
B. Normal saline or LR bolus 20 ml/kg over 1 hour
The patient in the prior question becomes increasingly lethargic and you are unable to arouse her. You also note pupillary dilation bilaterally. Her RR is regular at 36, and she is maintaining an O2sat of 98% on RA. You immediately should:
A. Stop the insulin drip B. Increase the insulin drip rate C. Give mannitol 0.5 mg/kg IV tx the cerebral edema D. Send her for a stat CT of the head E. Consult pediatric endocrinology
C. Give mannitol 0.5 mg/kg IV tx the cerebral edema!!
