Pediatric DKA

This case is written by Dr. Donika Orlich. She is an Emergency physician practising in the Greater Toronto Area. She completed her Emergency Medicine training at McMaster University and also obtained a fellowship in simulation and medical education during her training.

Why it Matters

DKA is a reasonably common presentation to the ED. However, it requires several important steps in its management in order to prevent harm. This is especially true in children, where the rates of cerebral edema are higher. This case highlights several important features in the management of Pediatric DKA, including:

  • That there is no role for an insulin bolus.
  • That the precipitant of DKA must always be considered (in this case, it is appendicitis)
  • That cerebral edema is a known complication of DKA and must be managed immediately with a reduction in the insulin and fluid rates as well as with either mannitol or hypertonic saline

We have previously published a case of Pediatric DKA on emsimcases. Today’s case is unique in that it begins with the learners providing advice over the phone to a physician who is less comfortable managing DKA.  We have chosen to publish on this topic a second time as a way to emphasizes how cases on the same topic can be designed with different objectives in mind. The objectives (and therefore the case design) can lead to very different learning experiences. We have no doubt that this new case will also lead to excellent debriefing and evidence review with learners – it certainly does when we run it for our senior residents at McMaster University!

Case Summary

The learners receive a call from a peripheral hospital about transferring an unwell 8-year-old girl with new DKA. She has been incorrectly managed, receiving a 20cc/kg bolus for initial hypotension as well as an insulin bolus of 8 units (adult sliding scale dose for glucose of >20). The learner must perform a telephone consultation and dictate new orders. On arrival, EMS will state that they lost the IV en route, and the patient will become more somnolent in the ED. The learner should begin empiric treatment for likely cerebral edema and concurrently manage the DKA. Physical exam will show a peritonitic abdomen with guarding in the RLQ. Empiric Abx should be started for likely appendicitis. Due to decreasing neurologic status and vomiting, the patient will eventually require an advanced airway. The challenge is to optimize the peri-intubation course and ventilation to allow for compensation of her metabolic acidosis.

Clinical Vignette

Outside Patch: We have an 8-year-old female we want to send for DKA. She presented after feeling generally “unwell” for 3 days, with some accompanying abdominal pain and vomiting. Her blood glucose came back at 24 with a pH of 7.15 and HCO3 of 12, so we made the diagnosis of DKA. She received a 20mL/kg bolus for hypotension (BP 90/60) and Humulin R 8 unit bolus (as per our hospital sliding scale). What do you want for insulin and fluids before we send her?

Download the case here: Pediatric DKA

Post-intubation CXR for the case found here:

normal-intubation2

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

DKA

This case is written by Dr. Lindsey McMurray. She is a PGY4 Emergency Medicine resident from the University of Toronto who is currently doing a Resuscitation and Reanimation fellowship at Queen’s University.

Why it Matters

DKA is a physiologically complex disorder. Thanks to excellent research and protocolization of care, certain components of DKA care have been clearly delineated. However, in the profoundly unwell DKA, it can be harder to account for complex physiology. This case highlights a few important management pearls:

  • The importance of re-assessing glucose in an altered patient with DKA on an insulin infusion
  • The consideration of cerebral edema in a DKA patient who becomes altered
  • The importance of expertly managing acidosis in the peri-intubation period by considering pre and post intubation respiratory rate

Our reviewers had quite the debate about what is considered optimal peri-intubation management in this patient. This case serves as an excellent starting point for a high-level discussion about the intubation of a severely acidotic patient. In particular:

  • Pre-intubation bicarbonate is relatively contraindicated in Peds DKA. Balancing the increased acidosis peri-intubation against the increased risk of cerebral edema is challenging.
  • A second IV fluid bolus pre-intubation is also controversial. Would it increase the risk of cerebral edema?
  • Is intubation with or without a paralytic the best choice? Using a paralytic optimizes time to intubation and first pass success, as well as minimizing aspiration risk. But it also eliminates the patient’s respiratory drive, which could potentially worsen acidosis and precipitate arrest. Not using a paralytic runs the risk of increased time to intubation and a resultant desaturation. It also adds an aspiration risk.

For this, and so many other reasons, this case will trigger plenty of discussion during debriefing!

Clinical Vignette

You have been called to the resuscitation bay to assess an 8 year old girl who has been brought in by her mother for lethargy and confusion. She has been unwell for 3 days with excessive fatigue, a few episodes of vomiting, and mild abdominal pain.

Case Summary

An 8 year old girl who has been tired and “unwell” for several days presents to the ED with an acute decline in her mental status. She is confused and lethargic. It becomes quickly apparent that the child is in DKA and requires immediate treatment. Due to decreasing neurologic status and vomiting, she eventually requires an advanced airway. The challenge is to optimize the peri-intubation course and to appropriately ventilate to allow for compensation of her metabolic acidosis.

Download the case here: DKA Case

CXR for case found here:

Normal Post-Intubation CXR

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)