Makindo Medical Notes

🩺 Initial Assessment

• 📝 History & Exam: Look for vomiting 🤮, abdominal pain, dehydration (dry lips, sunken eyes), lethargy 💤, and deep breathing (Kussmaul respiration 🫁). Check for infection as a precipitating factor.
• ❤️ Vital Signs: Record heart rate, respiratory rate, BP, capillary refill, oxygen saturation, and temperature 🌡️.
• 💡 Key point: DKA can mimic sepsis → always think about dual pathology.

📖 BSPED Guideline

• UK guideline follows ISPAD definition: pH <7.3 or HCO₃ <15 mmol/L with ketones >3.0 mmol/L = DKA ✅

📊 BSPED Severity Classification

• 🟢 Mild: pH 7.2–7.29 or HCO₃ <15 → assume 5% dehydration.
• 🟠 Moderate: pH 7.1–7.19 or HCO₃ <10 → assume 5% dehydration.
• 🔴 Severe: pH <7.1 or HCO₃ <5 → assume 10% dehydration.

💡 Clinical Pearl: Careful, gradual rehydration is essential ⚖️ – too rapid fluids ↑ risk of cerebral oedema. But shock = resuscitate first.

🔎 Investigations

• 🧪 Bloods: Glucose, VBG/ABG (pH, HCO₃), Na⁺, K⁺, urea, creatinine.
• 💧 Urine: Dip for ketones.
• 🦠 Infection screen: CXR, cultures if infection suspected.
• ⚡ ECG: Monitor potassium (peaked T waves in hyperkalaemia, flattened T in hypokalaemia).

⚡ Initial Management

• 🫁 Airway: Ensure patency. Insert airway if comatose. NG tube if reduced consciousness to prevent aspiration.
• 💨 Breathing: Give 100% O₂ if hypoxic. Watch for Kussmaul breathing.
• 💓 Circulation: Insert IV access, monitor BP/HR, start cardiac monitoring.
• 💉 Shocked child: Give 10 ml/kg 0.9% NaCl bolus 💧 (repeat if persistent shock). Discuss with senior/ICU early.
• 💧 Not shocked: Give 10 ml/kg 0.9% NaCl over 30 min (some centres use PlasmaLyte).
• 💊 Insulin: Start low-dose infusion after fluids (0.05–0.1 units/kg/hr). ❌ No bolus.
• ⚡ Potassium: Replace once U&E available – insulin drives K⁺ into cells → risk of hypokalaemia ⚠️.
• 👀 Monitoring: Check glucose, ketones, electrolytes, gases every 1–2 hrs. Perform neuro checks for cerebral oedema.
• 🦠 Treat triggers: Infections, missed insulin, new diabetes diagnosis.
• 🍽️ Transition: When ketones cleared + child eating, switch to SC insulin.
• 📚 Education: Teach family about diabetes care, sick day rules, and recognising early DKA signs.

☠️ Causes of Death in DKA

• 🧠 Cerebral oedema: Most feared complication. Often in young/newly diagnosed children. Mortality ~25%.
• ⚡ Hypokalaemia: Preventable with careful replacement.
• 🌬️ Aspiration pneumonia: Use NG tube if vomiting or reduced consciousness.
• 💔 Inadequate resuscitation: Poor perfusion worsens brain injury risk. Always treat shock aggressively.

📚 References

• BSPED Guideline 2021 – DKA in Children & Young People