Initial Emergency Assessment

Fig 2: 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 [19,22]:

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
  • and or recent consumption of a large volume of fruit juice or high sugar drinks [24, 25]

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 [26] a 12 lead ECG, and evaluate for T wave changes
  • Assess for signs of shock
• All patients should be given fluid replacement and this should occur before insulin. The rate of fluid is dependent on if they are shocked or not.
• Shock is defined as tachycardia, prolonged central capillary refill, poor peripheral pulses and hypotension. Hypotension is a late sign of shock. Shock is not just poor peripheral perfusion as this can be due to acidosis and hyocapnia, both of which can cause peripheral vasoconstriction.
• Shocked patients should receive 10ml/kg bolus of 0.9% Saline over 15 minutes.
• Following the initial 10 ml/kg bolus shocked patients should be reassessed and further boluses of 10 ml/kg up to a total of 40 ml/kg may be given if required, at which stage inotropes should be considered.
• Non shocked patients, with mild, moderate or severe DKA should receive a 10 ml/kg 0.9% sodium chloride bolus over 30 minutes. 

Initial investigations

• Blood glucose
• Blood gases (venous or capillary)
• Ketones- point of care blood tests (are superior to urinary ketones as they provide a rapid result and a quantitative rather than qualitative result)
• FBC
• Urea and electrolytes (electrolytes on blood gas sample may give a guide until accurate results available)
• CRP
•  If able to obtain sufficient blood and this is a new diagnosis, send new diagnosis investigations (HbA1c,TFT, Coeliac screen)

Other investigations should be done only if indicated e.g. CXR, blood or urine culture etc.