Altered Conscious Level

Question 1

What is DKA?

Answer 1

Severe lack of insulin means the body cannot use intracellular glucose
Body breaks down other body tissue as an alternative energy source
Ketones are the by-product of this process which build up and cause the body to become acidic

Question 2

When does DKA usually occur?

Answer 2

At diagnosis of DM
During a growth spurt/puberty
Insulin omission
When ill
When an insulin pump gets blocked

Question 3

When do you diagnose DKA?

Answer 3

Acidosis - pH <7.3 (Severe <7.1)
Ketonaemia (Blood beta-hydroxybutyrate >3mmol/L)
Blood glucose >11

Question 4

What is Kussmaul breathing?

Answer 4

Form of hyperventilation
Deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA)
Also kidney failure

Question 5

Treatment for DKA

Answer 5

Treat DKA with oral fluids and subcutaneous insulin only if the child or young person is:
Alert
Not nauseated or vomiting, Not clinically dehydrated

IV fluids and IV insulin if the child or young person is:
Not alert
Nauseated or vomiting
Clinically dehydrated

Question 6

Calculating a fluid requirement for children with DKA

Answer 6

Assume a:
5% fluid deficit in mild to moderate DKA
10% fluid deficit in severe DKA

Lower than usual - Large fluid volumes associated with increased risk of cerebral oedema

Question 7

Neccesary monitoring in DKA

Answer 7

1 hourly monitoring of:
BM
Ketones
Vital Signs
Fluid balance
GCS

@ 2 hours and then evey 4
monitor:
Glucose
Blood pH
pCO2
Na, K, urea

Monitor children receiving IV therapy with ECG

Question 8

Assess child for cerebral oedema if which conditions are present?

Answer 8

Headache
Agigitation or irritability
Unexpected ↓HR & ↑BP

Question 9

What is the treatment of cerebral oedema?

Answer 9

Mannitol or

Hypertonic sodium chloride

Question 10

When to treat for cerebral oedma

Answer 10

Deterioration in level of consciousness
Abnormalities of breathing pattern (for example respiratory pauses)
Oculomotor palsies
Pupillary inequality or dilatation

Question 11

When to suspend insulin infusion

Answer 11

Hypokalemia (<3mmol/L)

Child may need a central line to deliver IV K+

Question 12

Symptoms of T1DM

Answer 12

Polyuria
Polydipsia
Weight loss
Excessive tiredness

Question 13

Diagnosisng diabetes

Answer 13

Fasting glucose >7

2hr palsma glucose >11.1

Question 14

Monitor children ith T1DM for: (4)

Answer 14

Thyroid disease (at diagnosis, then anually)
Diabetic retinopathy - anually from 12
ACR for albuminuria - anually from 12
Hypertension - anually from 12

Question 15

Rare complications to be aware of in T1DM

Answer 15

Juvenile cataracts
Necrosis Lipoidica
Addison’s Disease

Question 16

Initial management of DKA

Answer 16

O2
IV fluids
IV insulin
Consider NGT if drowsy
Consider Abx
Discussion with diabetes team

Question 17

Indications for T2DM in children

Answer 17

Strong family history
Signs of insulin resistance - acanthos nigricans
Obese at prsentation
Black or Asian family origin
Have no insuin requirement/ <0/5units/kg

Question 18

Indications for caauses other than T1 or T2DM

Answer 18

Diabetes in the first year of life
Rarely or never develop ketone bodies in the blood (ketonaemia) during episodes of hyperglycaemia
Associated features: optic atrophy, retinitis pigmentosa, deafness, or another systemic illness or syndrome
Strong family history of diabetes(however type 1 diabetes also has a genetic component)

Question 19

What is the main danger of childhood DKA?

Answer 19

Cerebral oedema

• Occurs in ~1% of DKA cases
• Mortality rate of 25%

(Hypokalemia, aspirational pneumonia)

Question 20

What may be the cause if ketonuria but glucose normal

Answer 20

Alcohol

Question 21

What to consider if acidosis but normal glucose?

Answer 21

Poisoning - aspirin

Question 22

Amylase in DKA

Answer 22

Often raised (up to ten fold) with non-specific abdominal pain even in absence of pancreatitis