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Children's Health > Altered Consciousness > Flashcards

Altered Consciousness Flashcards

1
Q

List 3 causes for tachycardia in a teenage patient

A
  1. Hypovolaemic shock
  2. Use of medications e.g. salbutamol
  3. Anxiety
  4. Cardiac arrhythmia (secondary to electrolyte imbalance)
  5. Co-existing endocrine conditions e.g. hyperthyroidism
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2
Q

List 4 causes for abnormal respiration patterns in teenage patients

A
  1. Endocrine - DKA (Kussmaul breathing?)
  2. Asthma exacerbation
  3. Chest infection
  4. Cardiac disease
  5. Metabolic - acidosis or alkalosis compensation?
  6. Anxiety
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3
Q

What may cause agitation in a child presenting acutely unwell?

A
  1. Hypoglycaemia - due to vomiting
  2. Exhaustion - IWOB
  3. Hypocapnia - secondary to hyperventilation
  4. Cerebral oedema
  5. DKA
  6. Encephalopathic due to infection (viral or bacterial) or high ammonia
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4
Q

What is diabetic ketoacidosis (DKA) and what is its pathophysiology?

A
  • A consistently high blood glucose can lead to DKA.
  • This happens when there is a severe lack of insulin, meaning intracellular glucose cannot be used for energy so the body begins to break down other body tissues as an emergency energy source.
  • Ketones are a byproduct of this process.
  • Ketones are poisonous and if they are left for too long the body becomes acidic.
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5
Q

DKA is a life-threatening emergency! When is it most common for someone to have DKA?

A
  1. At diagnosis - many do not realise they have T1DM until they become very unwell with DKA
  2. When they are ill (viral infection etc)
  3. During a growth spurt/puberty
  4. When insulin has been omitted
  5. DKA usually develops over 24 hours, but can be faster in young children
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6
Q

When would you take a capillary blood glucose measurement from a child/young person?

A

If they present with increased thirst, polyuria, recent unexplained weight loss or excessive tiredness and they DO NOT know they have diabetes with any of the following;

  • N+V
  • Abdominal pain
  • Hyperventilation
  • Dehydration
  • Reduced level of consciousness
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7
Q

At what level plasma glucose, in a patient with or without diabetes, would you suspect DKA (if they have signs suggestive of DKA)?

A

> 11 mmol/L

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8
Q

What signs would lead you to suspect DKA in a child with known diabetes?

A
  1. N+V
  2. Abdominal pain
  3. Hyperventilation
  4. Dehydration
  5. Reduced level of consciousness
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9
Q

What would you test in a child with known diabetes if you were suspecting DKA?

A

Blood ketones

Blood glucose

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10
Q

What measurements would be taken from a child who has been referred to hospital with suspected DKA?

A
  1. Capillary blood glucose
  2. Capillary blood ketones (use to be urinary but this is no longer deemed accurate)
  3. Capillary/venous pH and bicarb
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11
Q

When can you diagnose DKA in a child/young person with diabetes?

A
  1. Acidosis - Blood pH <7.3 or plasma bicarbonate below 18 mmol/l
  2. Ketonaemia - blood beta-hydroxybutyrate >3
  3. If blood pH <7.1 then this is SEVERE DKA
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12
Q

What are the causes of Kussmaul breathing?

A

DKA and Hyperpnoea is common

K - Ketones 
U - Uraemia 
S - Sepsis
S - Salicylates 
M - Methanol
A - Aldehydes 
U 
L - Lactic acid/acidosis
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13
Q

What is Kussumaul breathing?

A

Deep and laboured breathing pattern, often associated with severe metabolic acidosis.

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14
Q

When can a child with DKA be given IV fluids and IV insulin?

A
  1. If they are not alert
  2. If they are nauseated or vomiting
  3. If they are clinically dehydrated
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15
Q

What is the warning from NICE about giving oral fluids to a child receiving IV fluids with DKA?

A

DO NOT give oral fluids to a child/young person receiving IV fluids for DKA unless their ketosis is resolving, they are alert and have no N+V

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16
Q

What percentage fluid deficient should you assume in a child with; mild to moderate DKA (blood pH 7.1

A

5% deficient

17
Q

What percentage fluid deficient should you assume in a child with; severe DKA (blood pH 7.1>)?

A

10% deficient

18
Q

How do you calculate the total fluid requirement of a child with DKA for the first 48 hours?

A

Estimated fluid replacement + Fluid maintenance requirement

19
Q

How do we calculate the maintenance fluid requirement in children with DKA?

A

Reduced volume rules must be used;

  • If they weigh <10kg then give 2ml/kg/hour
  • If they weigh between 10 and 40kg then give 1ml/kg/hour
  • If they weigh >40kg then give a fixed value of 40ml/hour
20
Q

Why should the volume of fluids given to a patient with DKA be reduced compared to the non-DKA dehydrated child?

A

Larger fluid volumes are linked with an increased risk of cerebral oedema this is why rehydration is carried out slowly over the first 48 hours

21
Q

Which fluid should be used in DKA patients and why?

A

0.9% NaCl WITHOUT glucose unless their glucose is below 14mmol/l.
This is because they will already have hyperglycaemia so glucose will be harmful not helpful

22
Q

How long after starting IV fluids should IV insulin be started?

A

1-2 hours after IV fluid therapy has commenced

23
Q

How much IV insulin infusion should be given per hour to a patient with DKA?

A

0.05-0.1 units/kg/hour

24
Q

What should be monitored and recorded in the notes, at least hourly, in children/YA with DKA?

A
  1. Capillary blood glucose
  2. Ketones
  3. Vital signs (HR, RR, BP, Temp)
  4. Fluid balance
  5. Fluid input and output charts
  6. Level of consciousness
25
Q

How often should we record level of consciousness in children under 2 years of age and why?

A

Every 30 minutes

They are at increased risk of cerebral oedema

26
Q

What further investigation should be monitored continuously in children/YA who are receiving IV therapy for their DKA?

A

A continuous ECG to detect any signs of hypokalaemia

27
Q

2 hours after commencing treatment (and every 4 hours thereafter) what blood measurements should be recorded in those with DKA?

A
  1. Blood glucose

2. Blood gas - pH, pCO2, Na, K, Urea

28
Q

How often should a clinician review a child/YA with DKA face-to-face?

A

4 hourly at least

29
Q

What are the most common complications of DKA?

A
  1. Cerebral oedema
  2. Hypokalaemia
  3. VTE
30
Q

What are the signs/symptoms of Cerebral oedema in a DKA patient?

A
  1. Headache
  2. Agitation
  3. Irritable
  4. Unexpected bradycardia and hypertension
31
Q

How would you treat cerebral oedema in DKA?

A

Mannitol (20% 0.5-1g/kg over 10-15 minutes)

Children's Health (14 decks)

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