diabetic ketoacidosis

Question 1

emergency management: diabetic ketoacidosis first steps

Answer 1

ABC call for senior help

Question 2

what can the patient die from?

Answer 2

cerebral oedema
hypokalemia
aspiration pneumonia

Question 3

symptoms of DKA diagnostic criteria

Answer 3

hyperglycemia- BG greater than 11
PH less than 7.3 
bicarbonate less than 15 
and 
dehydrated, vomiting, drowsy, and clinically acidotic

Question 4

airway

Answer 4

ensure that the airway is patent if comatose insert a airway
if vomiting insert NG tube, aspirate and leave fro open drainage

Question 5

breathing

Answer 5

100% oxygen by face mask

Question 6

circulation

Answer 6

insert IV cannula and take blood samples and cardiac monitor for T waves

Question 7

what are the symptoms of shock?

Answer 7

poor peripheral pulses, poor cap refill plus tachycardia, and or hypotension

Question 8

if the child is in shock what do you do?

Answer 8

give 10 ml/kg 0.9% normal saline as a bolus and repeat to a maximum of 30 ml/kg

Question 9

after general resuscitation what is the next step?

Answer 9

confirm the diagnosis
history: polydispsia, polyuria
clinical: blood gas- respiratory acidosis
dehydration drowsiness and abdominal pain and vomiting

Question 10

what would you be expecting int he blood gas?

Answer 10

A blood ph less than 7.3

and a HCO3 less than 15mmol/L

Question 11

what biochemical investigations would you consider in this patient?

Answer 11

blood glucose greater than 11
venous blood gas - ph less than 7.3 and HCO3 less than 15
finger prick greater than 3
glucose and ketones in the urine

Question 12

how do you assess the degree of dehydration?

Answer 12

mild- 3% only just detectable
moderate 5% dry mucous membranes skin turgor reduced
severe 8% above the sunken eyes poor cap refill
shock poor perfusion thready rapid pulse

Question 13

what would you assess after dehydration status?

Answer 13

degree of consciousness

Question 14

what are the sign of cerebral oedma ?

Answer 14

headache, irritability my slowing pulse rising blood pressure, reduced level of consciousness

Question 15

what other signs beside cerebral oedema would you be looking for?

Answer 15

infection and lieus

Question 16

what is the formula for calculating fluids?

Answer 16

requirement= maintainence plus deficit minus fluid already given

Question 17

what type of fluid will you use to resus?

Answer 17

normal 0.9% saline with 20mmol KCL in 500ml and continue for at least 12 hours

Question 18

when do you add glucose back into the fluid resus?

Answer 18

fallen to 14 mmol/L

Question 19

calculate the fluid resuscitation needed per hour

37 kg girl with 3% dehydration and has been given 20ml/kg bolus

Answer 19

77ml. hr

Question 20

after 12 hours what should you consider with the fluids?

Answer 20

you should look at the Na levels to see if they are stable or increasing if they are change to .45% saline or
if falling continue with normal saline.

Question 21

when should you check U&Es?

Answer 21

two hours after resus

Question 22

when could you consider oral fluids?

Answer 22

as soon as the patient is stabilised and good clinical improvement.

Question 23

After you have resuscitated the patient with Na saline, which electrolyte would you be concerned about?

Answer 23

Potassium - intracellular and levels in the blood will fall after insulin is commenced.
every 500ml bag of fluid contains 20mmol KCl

Question 24

when do you start insulin?

Answer 24

NOT RIGHT AWAY… because once the child is being resusitatrf glucose levels in the blood will start to fall. SO it needs to retrained from starting at least an hour.

Question 25

what is the preferred infusion of insulin?

Answer 25

continuous low dose 1 unit per ml of human insulin | 50 units to 50ml in a syringe pump.

Question 26

how fast do you infuse insulin?

Answer 26

0.1 units per hour

Question 27

if the blood glucose falls below 14mmol/L switch off the insulin??

Answer 27

NO! just add glucose into the fluid bag! 5% still maintain 0.1 units per kg later if the PH is normal then can lower the dose of insulin but don’t stop it!!!

Question 28

when should bicarb be considered?

Answer 28

severely acidotic Ph less than 6.9

Question 29

should you replace phosphate?

Answer 29

nope

Question 30

should you be worried about anticoagulants?

Answer 30

YES children with DKA are at greater risk of femoral vein thrombosis- fragmin 100 units per kg

Question 31

what are some important things to do in all emergency situations?

Answer 31

DOCUMENTATION!

Question 32

what are some causes for the acidosis not to correct after treatment?

Answer 32

``` not enough insulin to switch off ketogenesis not enough resus sepsis hyperchloremic acidosis asprin or other overdose ```

Question 33

how do you manage insulin once ketogenesis is resolved?

Answer 33

discontinue insulin IV for 60 minutes once ketones are less than 1 and you have given subcut insulin.

Question 34

what are the signs of cerebral oedema?

Answer 34

cushings reflex headache bradycardia, rising bp neurological status abnormal posturing

Question 35

management of cerebral oedema?

Answer 35

exclude hyperglycemia as the possible cause of change give mannitol 0.5g/kg per hour fluid restrict to half the maintance dose and replace slower admit to PICU

Question 36

glasgow coma scale

Answer 36

best motor response 1-6 none, extensor, abnormal flexion, withdrawal from pain, localizes pain, responds to commands eye- 1-4 none, pain, speech, alert verbal- none, sounds, inappropriate words. appropriate words but confused, and fully oriented.