Initial Emergency Assessment

Fig 6: Patients with DKA can be critically ill at presentation and should be managed systematically

Airway, breathing and circulation form part of the initial emergency management of paediatric DKA [22,25]:

Airway

• Ensure patent
• Consider adjuncts or definitive airway if indicated
• Seek anaesthetic support if there are concerns
• Due to the high risk of aspiration pneumonia an NG tube should be seriously considered in the following situations:
  • a child with reduced level of consciousness
  • and/or recurrent vomiting
  • & or recent consumption of a large volume of fruit juice or high sugar drinks[28-29]

Breathing

• Give 100% oxygen by non re-breathe mask

Circulation

• Obtain IV access
  • Ideally 2 points of access
  • Avoid central access due to increased risk of thrombus
• Attach patient to a cardiac monitor[30,31]
  • Perform a 12 lead ECG, and evaluate for T wave changes, and assess for signs of shock
• All patients should be given fluid replacement and this should occur before insulin/immediately. The amount of fluid is dependant on if they are shocked:
  • Shocked patients (heart rate, capillary refill time):
    • 20ml/kg of 0.9% (normal) saline over 15 minutes
    • If required, further 10ml/kg boluses up to a maximum of 40ml/kg at which point inotropes should be considered
    • Boluses for shocked patients should not be subtracted from the fluid deficit
  • Non-shocked patients
    • 10ml/kg bolus of 0.9% (normal) saline over 60 minutes
    • Do not give more than 10ml/kg without decision with the responsible consultant
    • Boluses for non-shocked patients should be subtracted from the fluid deficit

Confirm the diagnosis

Initial investigations

• Blood glucose
• Laboratory U&Es, Osmolality, FBC, CRP, Albumin, Calcium, Phosphate and Magnesium
• Venous blood gas
  • pH and PC02 are comparable to arterial samples
  • Blood gas electrolytes are useful in guiding early fluid management before laboratory results are available
• Blood ketones
  • Near patient test similar to bedside glucose meters
  • Superior to urinary ketones as:
    • Rapid result
    • Quantitative rather than qualitative (mmol/L)
• ECG

NB: Other investigations should only be performed if indicated (i.e. septic screen in patients who are febrile, CXR etc.)