Paediatric Emergencies

A presentation showing the basics and presentation of common paediatric emergencies

1. PAEDIATRIC
EMERGENCIES
DR.S SEN
Specialist Registrar Paediatrics
North Western Deanery

2. 05/29/09 SHO INDUCTION/DR.S.SEN 2
PAEDIATRIC EMERGENCIES
1. COMA
2. SHOCK (Septicaemia, anaphylaxis)
2. UPPER AND LOWER AIRWAY OBSTRUCTION
Croup and Epiglottitis, Foreign Body
Asthma, Bronchiolitis, Chest infection
3. CARDIAC EMERGENCIES
Heart Failure
Supraventricular Tachycardia

3. 05/29/09 SHO INDUCTION/DR.S.SEN 3
PAEDIATRIC EMERGENCIES
4. INFECTIONS
lMeningitis
lEncephalitis
lKawasaki
lHUS
lPertussis
lEndocarditis
5. SEIZURES
lStatus epilepticus
lFebrile fits
lHypsarrhythmia
lNon febrile fits
lIncreased
intracranial
pressure

4. 05/29/09 SHO INDUCTION/DR.S.SEN 4
PAEDIATRIC EMERGENCIES
6. RENAL
lHypertension
lHaematuria
lUTI
lNephrosis
lHUS
7. SKIN
lRash, Erythema
lPurpura, Petechia
lPeeling
lVesicles, Pustula
lCellulitis
lNAI

5. 05/29/09 SHO INDUCTION/DR.S.SEN 5
PAEDIATRIC EMERGENCIES
8. PAINS
lLimping child
lChest pain
lAbdominal pain
lHeadache
lBackache
lSickle Cell
9. ENVIRONMENTAL
§Burns, smoke inhalation
§Drowning
§Poisoning
§Hypothermia, heat stress
§Anaphylaxis
§Head injury and RTA
§NAI and SA

6. 05/29/09 SHO INDUCTION/DR.S.SEN 6
EMERGENCIES IN BABIES
§Excessive crying
§Not feeding
§Cyanosis
§Apnoea
§Jaundice
§Fitting
§Diarrhoea
§Vomiting
§Fever
§Bleeding

7. 05/29/09 SHO INDUCTION/DR.S.SEN 7
COMA
STATE OF UNRESPONSIVENESS DUE TO DIFFUSE
LESIONS OF HEMISPHERES / BRAIN STEMS
§Structural lesions
lbleeding, tumour, abscess, hydrocephalus
§Non-structural lesions (95%)
lseizures, drugs / poisons
linfection (meningitis, encephalitis, HUS)
lmetabolic (hypoglycaemia, DKA, Reye)
lrenal failure, hepatic coma
lendocrine (Addison)

8. 05/29/09 SHO INDUCTION/DR.S.SEN 8
COMA: ASSESSMENT AND DIAGNOSIS
Rapid History and General Examination
uSkin (trauma, petechiae, bleeding)
uSutures in infant and neck stiffness, systemic, AF
CNS examination
uGCS, Gag R, Blinking
uPupils, Reaction, EOM Palsy, Fundi, Dolls Eye
uMotor- Posture, Tone, Symmetry/Lateralizing signs
uReflexes- DTR, Plantars
uPain, Grimace, Flexion, Extension, None
uAssess level of Central Dysfunction

9. 05/29/09 SHO INDUCTION/DR.S.SEN 9
CHILDREN’S COMA SCORE (15)
Eyes: 4 spont. open
3 verbal command
2 pain
1 no response
Motor:6 obeys verbal
5 localizes pain
4 withdraws from pain
3 abn. flexion to pain
2 extends to pain(decer)
1 no response
Best verbal response:
5 orientated
smiles, follows
4 disorientated
consolable crying
inapropriate interaction
3 inappropriate words
sometimes consolable
moaning
2 incomprehensible sounds
inconsolable, irritable
1 no response

10. 05/29/09 SHO INDUCTION/DR.S.SEN 10
MANAGEMENT OF COMA
Always emergency - get Registrar/Consultant
Airways - check, suction, ventilation if needed
Breathing - ensure adequacy: RR, BS,saturation
lGive high flow oxygen, if breathing
lVentilate with bag and mask
lIntubate with Anaesthetist, if
breathing inadequate / GCS 8 / herniation syndromes
Circulation - monitor BP, CRT, PR
liv access: 2 venous and arterial lines

11. 05/29/09 SHO INDUCTION/DR.S.SEN 11
INVESTIGATIONS IN COMA
§FBC, U+E, LFT, BC, Blood gases, Glucose,
§NH3, toxic screen, lactate, aminoacids,
ammonia,
§Virus studies, PCR
§Chest X-ray, EEG
§CT scan (has limited value),
§LP only with neurosurgical support

12. 05/29/09 SHO INDUCTION/DR.S.SEN 12
TREATMENT OF COMA
§Treat Shock - Restore and control BP
§Treat The Treatable
lMaintain BS with 10% dextrose 5mls/kg PRN
lRestricted fluid (document type & rate)
lMannitol, if increased intracranial pressure
lConsider Cefotaxime, Acyclovir, Erythromycin
lConsider Flumazenil, Naloxone, Anticonvulsant
§May require transfer to PICU

13. 05/29/09 SHO INDUCTION/DR.S.SEN 13
SHOCK
Failure of circulation of oxygen to tissues
resulting in lactic acidosis, cellular dysfunction
and cell death
1. Hypovolaemic shock due to loss of blood or fluid
2. Distributive (septic) shock: maldistribution of blood
3. Obstructive shock: reduced vascular size
4. Cardiogenic shock: primary heart problem

14. 05/29/09 SHO INDUCTION/DR.S.SEN 14
1. HYPOVOLAEMIC SHOCK
§Haemorrhagic loss:
trauma, gastrointestinal bleed, coagulopathy
§Fluid and electrolytes:
gastroenteritis, diabetic ketoacidosis, polyuric
states, mineralocorticoid deficiency
§Plasma/ protein loss:
burns, peritonitis, bowel obstruction/ necrosis

15. 05/29/09 SHO INDUCTION/DR.S.SEN 15
2. SEPTIC (DISTRIBUTIVE) SHOCK
MALDISTRIBUTION OF BLOOD WITHIN ORGANS DUE
TO ABNORMAL PERIPHERAL FUNCTION
§Sepsis: Gram negative bacteria, Meningococcus
§Neurogenic shock
§Drugs: antihypertensives, barbiturates
§Anaphylaxis

16. 05/29/09 SHO INDUCTION/DR.S.SEN 16
REDUCED VASCULAR SIZE AND LIMITED BLOOD FLOW
DUE TO INTRINSIC OR EXTRINSIC FACTORS
§Pericardial tamponade
§Tension pneumothorax
§Pulmonary embolism
3.OBSTRUCTIVE SHOCK

17. 05/29/09 SHO INDUCTION/DR.S.SEN 17
4.CARDIOGENIC SHOCK
PRIMARY HEART PROBLEM WITH INADEQUATE
CARDIAC OUTPUT AND INADEQUATE TISSUE
PERFUSION
§SVT, bradycardia, ventricular tachycardia
§Myocarditis
§Hypoplastic left heart
§Left sided outflow obstruction
§Critical aorta stenosis and coarctation of aortae

18. 05/29/09 SHO INDUCTION/DR.S.SEN 18
ASSESSMENT OF SHOCK
Full history and physical examination
Classic signs:
tachycardia, tachypnoea,
oliguria (anuria),
weak pulse, mottled extremities,
hypotension
òChildren can compensate for hypoperfusion states
òHypotension is a late sign of decompensated shock

19. 05/29/09 SHO INDUCTION/DR.S.SEN 19
EARLY AND LATE SHOCK
tachycardia è bradycardia, dysrhytmia
tachypnoea è severe tachypnoea and gasping
low pulse pressure è hypotension
cool extremities, decreased CR è absent peripheral pulses
dry mucosa è mild oliguria è severe oliguria è anuria
restlessness / agitation è unconsciousness

20. 05/29/09 SHO INDUCTION/DR.S.SEN 20
GENERAL MANAGEMENT OF SHOCK
MONITOR: HR, BP, BP (CVP), O2 sat., fluid balance
AIRWAY, BREATHING, CIRCULATION
lReverse hypoxia and acidosis
lControl bleeding with direct pressure
lObtain intravenous (arterial) access
INVESTIGATIONS:
lFBC, U+E+osm, LFT (fibr, glu), BG, BC, clotting, BG
lMSU, X-ray, ECG, Brain scan
TRANSFER TO ITU:
lno response to Dopamine 2-20ugm/kg/min
lsigns of organ failure

21. 05/29/09 SHO INDUCTION/DR.S.SEN 21
SPECIFIC MANAGEMENT OF SHOCK
§Hypovolaemia: rapid volume replacement
§Septic shock: antibiotics and inotropes
§Cardiogenic shock: minimal volume support
lInotropes (Dopamin, Dobutamine), if low BP+high HR
lChronotropes (Isoproterenol or Epinephrine),
if low BP + bradycardia or normal heart rate
§Obstructive shock: drainage
§Anaphylaxis: oxygen, adrenalin, hydrocortisone

22. RESPIRATORY FAILURES
Upper Airway Obstruction
Asthma (see BPA guideline)

23. 05/29/09 SHO INDUCTION/DR.S.SEN 23
ASTHMA ASSESSMENT
Mild Severe Life threat
Consciousness nil evolving+
Exhaustion nil evolving+
Cyanosis nil evolving+
Wheezy + + silent
Retraction nil/mild+ ++
Accessory musclesnil + ++
PEFR % >50-60 <50 <33
Sat. in air <92%

24. 05/29/09 SHO INDUCTION/DR.S.SEN 24
ASTHMA TREATMENT
§NEBULISERS (use oxygen):
lSalbutamol: 5mg
lAtrovent 250 ugm
§STEROIDS:
lprednisolone 2mg/kg/day (max 40)
lhydrocortisone: 4mg/kg 6 hourly
§AMINOPHYLLINE (with paediatricians):
lloading dose: 5mg/kg
lmaint. 1mg/kg/hour (max 20mg/kg/day)

25. 05/29/09 SHO INDUCTION/DR.S.SEN 25
SYMPTOMS OF CROUP
§Babies and toddlers (rarely school children)
§Coughing (barking)
§Mild fever
§Inspiratory stridor (=croup)
§Intercostal, suprasternal or subcostal recession
§Use of accessory muscle use
Differentialdiagnosis of viral or spasmodic croup:
(Get a second opinion from ENT Consultant)
epigolottitis, bacterial tracheitis, laryngeal foreign body, retropharyngeal
abscess, infectious mononucleosis, angioneurotic oedema,
diphtheria

26. 05/29/09 SHO INDUCTION/DR.S.SEN 26
CROUP - ASSESSMENT
Mild croup: stridor only when crying / agitated
no hypoxia and comfortable
Moderate croup: stridor at rest
recession and tachypnoea, but no hypoxia
Severe croup: STRIDOR all the time
recession and tachypnoea, tachycardia
decreased breath sounds
HYPOXIA- MONITOR SATURATION
NO INVESTIGATIONS, PLEASE

27. 05/29/09 SHO INDUCTION/DR.S.SEN 27
CROUP - MANAGEMENT
Mild croup: comfortable, stridor only when crying
No treatment, reassure and discharge with advice to return
Moderate ê severe croup:
STRIDOR AT REST, recession and tachypnoea ê
HYPOXIA, stridor, tachycardia, decreased breath sounds
uKeep calm and nurse in warm room, in upright position
uOxygen if oxygen saturations <92%
uBudesonide (Pulmicort) 2mg nebulised
uDexamethasone (single dose) 0.6mg/kg
uAdrenaline (1:1000) 0.5mls nebulised with 5mls saline
repeat 0.5mls/kg (max. dose 5mls)

28. 05/29/09 SHO INDUCTION/DR.S.SEN 28
CROUP - CRITERIA FOR ADMISSION
§Stridor at rest
§Transport or phone difficulties
§Great distance from hospital
§Concerns over degree of supervision of the child
§Parental anxiety
§Timing of presentation
§Recent onset and course felt to be progressive.
§NO IMPROVEMENT FOR 4 HOURS AFTER NEDULISED
ADRENALINE (ICU admission, if remains hypoxic with
deteriorating respiratory distress after 2 doses)

29. 05/29/09 SHO INDUCTION/DR.S.SEN 29
EPIGLOTTITIS
Toxic child, fever, drooling, can't swallow, can't talk, no
cough.
Advice to GP and ambulance staff: any child with severe
stridor should be transported sitting on parent's lap with
mask oxygen. Paediatrician and Intensivist should be
waiting to receive the child. Inform ENT Consultant.
Admission is automatic. This is a very serious condition.
Monitoring of vital signs frequently (<4 hourly)
No investigations (except urine Haemophilus ag)

30. 05/29/09 SHO INDUCTION/DR.S.SEN 30
EPIGLOTTITIS - MANAGEMENT
Treatment before intubation: none. Adrenaline is not
helpful and may irritate glottis. Steroids is of no use.
5-10% of children may be managed without intubation:
§if they arrive in the morning
§if they can still just talk and swallow
§if the physician is experienced
§there is facility for close observation on ICU
Indication for intubation: the child is getting tired out
despite adrenaline or with falling saturation.
In ICU: bloods and iv 50 mg/kg Cefotaxime

31. 05/29/09 SHO INDUCTION/DR.S.SEN 31
MENINGOCOCCUS INFECTION
CLINICAL SIGNS
èSuspect in any child with sudden onset of
èfever with headache,
èvomiting,
èstiff neck or pain in neck,
èpetechial rash ( non blanching)
êOther features include photophobia, drowsiness or
confusion and signs of meningism
êA rapidly evolving red macular rash may precede the
typical petechial rash

32. 05/29/09 SHO INDUCTION/DR.S.SEN 32
MENINGOCOCCAL INFECTION
MANAGEMENT
ÊPatients with meningococcal infection should be
rapidly assessed in resuscitation room
ËMonitor HR, BP, O2 saturation, respiratory rate
ÌAct on A.B.C. of resuscitation if required
ÍFurther management depends on general
condition

33. 05/29/09 SHO INDUCTION/DR.S.SEN 33
MANAGEMENT OF SUSPECTED
MENINGOCOCCAL INFECTION
Relatively Well Child
§Insert 2 iv lines and collect blood for investigations
(clotting screen, venous gas, PCR, serum)
§Immediately start iv Ceftriaxone 80 mg/kg (repeat dose
in 12 hours, cont. 7 days)
§Assess Glasgow Meningococcal Scoring
§Inform CDC within 2 hrs of arrival of the patient
§Admit for 48 hrs

34. 05/29/09 SHO INDUCTION/DR.S.SEN 34
MANAGEMENT OF SUSPECTED
MENINGOCOCCAL INFECTION
Unstable Child
§Inform CDC, Anaesthetist and PICU
§Give oxygen via face mask (6 litres), intubate
§Site 2 iv lines and collect blood samples, do CXR
§Start iv Ceftriaxone 80mg /kg immediately
§Treat shock vigorously, use 4.5% HAS 20mls/kg over
10-30 mins (up to 60-80mls/kg may be required)
§Give Dopamine 2.5ug-5ug/kg/min, if impaired perfusion
has not responded to initial measures
§Glasgow Meningococcal Score and temperature hourly

35. 05/29/09 SHO INDUCTION/DR.S.SEN 35
MANAGEMENT OF SEVERE
MENINGOCOCCAL INFECTION:
Early selection for transfer to PICU
§Refractory hypotension
§Deteriorating sensorium / coma
§Meningococcal score of 8 or more (30 %
mortality)
§Rapid clinical progress of rash within 12 hrs
(extensive/ necrotic skin lesion)
§Metabolic acidosis pH < 7.3

36. 05/29/09 SHO INDUCTION/DR.S.SEN 36
CHILDREN’S COMA SCORE (15)
Eyes: 4 spont. open
3 verbal command
2 pain
1 no response
Motor:6 obeys verbal
5 localizes pain
4 withdraws from pain
3 abn. flexion to pain
2 extends to pain(decer)
1 no response
Best verbal response:
5 orientated
smiles, follows
4 disorientated
consolable crying
inapropriate interaction
3 inappropriate words
sometimes consolable
moaning
2 incomprehensible sounds
inconsolable, irritable
1 no response

37. 05/29/09 SHO INDUCTION/DR.S.SEN 37
STATUS EPILEPTICUS - MANAGEMENT
§Monitor vital signs (watch apnoea and hypotension)
§Give O2 100% by mask
§If not breathing: bag + mask / ventilate if required
§Investigations:
BMstix, U & E, Ca, BG, FBC, C+S, toxic screen
§Always admission
§Use minimum doses to control seizures

38. 05/29/09 SHO INDUCTION/DR.S.SEN 38
DRUGS IN STATUS EPILEPTICUS
MIDAZOLAM (im, oral, nasal, rectal)
iv 50-100-200 ugm/kg/dose (12-18yrs 300ugm/kg)
LORAZEPAM (im, oral, rectal)
iv 50-100 ugm/kg/dose (12-18yrs 4mg)
DIAZEPAM (oral, rectal, iv)
PR: < 3 yrs 5 mg, > 3 yrs 10 mg
iv bolus 200 - 400 ugm/kg slowly, repeat in 10 mins
(12-18 yrs 10-20 mg)

39. 05/29/09 SHO INDUCTION/DR.S.SEN 39
COMPARISON OF DRUGS FOR STATUS
Diazepam Lorazepam Midazolam
onset1-3 mins 2-5 mins 22--33 mmiinnss
duration>>20 hrs 4-6hrs ½½ --11 hhrr
half life20-100 hrs15 hrs 22--33 hhrrss
peak 30 mins 2 hrs 4455 mmiinnss
giveniv/ rectaliv/im/o/rectiivv//iimm//oo//rr//nnaassaall
iv ug/kg0.2-0.4 50-100 50 - 200

40. 05/29/09 SHO INDUCTION/DR.S.SEN 40
FURTHER DRUGS IN STATUS
PHENYTOIN (cardiac monitor: HR and BP)
20 mg/kg iv in normal saline over 10-20 mins
may repeat 20 mg/kg (do not use in febrile status)
PHENOBARBITONE (in febrile status)
15-20 mg/kg iv over 10 mins
(10-20 mg/kg iv may be repeated)
PARALDEHYDE (im abscess, iv CSF peak 20-60 mins)
rectal 0.4 ml/kg + equal volume of arachnis oil

41. 05/29/09 SHO INDUCTION/DR.S.SEN 41
NON-FEBRILE CONVULSION
The younger the child, the more likely is an underlying
disorder (lower threshold for investigation < 1 yr)
lintracranial space occupying lesions
lhypertensive encephalopathy
lmetabolic disturbance (hypoglycaemia,
hypocalcaemia)
linborn errors of metabolism
lcongenital and inherited disorders (TS)
History (prenatal and natal) and examination
Monitoring (pulse oximetry)

42. 05/29/09 SHO INDUCTION/DR.S.SEN 42
NON-FEBRILE CONVULSION:
INVESTIGATIONS
Blood for glucose, FBC, Na+K+Ca+P+Mg,
Toxicology, pH
Septic screen, incl.CXR
Babies:TORCH, PCV / Clotting screen, urine metabolic
screen, reducing substances
MRI /CT / Brain US
EEG 2-3 weeks after fit, except suspected infantile spasms

43. 05/29/09 SHO INDUCTION/DR.S.SEN 43
JITTERY OR FITTING BABY?
JITTERY
BABY
NEONATAL
SEIZURES
Abnormality of gaze or
eye movement
- +
Stimulus-sensitive
movements
+ -
Predominant movement
TREMOR CLONIC JERKING
Movements cease with
passive flexion
+ -

44. 05/29/09 SHO INDUCTION/DR.S.SEN 44
FITTING BABIES: MANAGEMENT
Urgent treatment is indicated because repeated seizures
may result in brain injury: hypoventilation and apnoea,
hypercapnia and hypoxemia leading to IVH
·Intubation
·Glucose if hypoglycemia is present: 2 ml/kg (200 mg/kg)
10% dextrose iv and maintainance on 8 mg/kg/min PRN
·Phenobarbital iv loading dose of 20 mg/kg in 10 minutes
·Phenytoin iv loading dose of 20 mg/kg (monitoring)

45. 05/29/09 SHO INDUCTION/DR.S.SEN 45
FEBRILE FIT - ASSESSMENT
§Accurate history of event
lAny preceding illness, including fever
lFunny turns, rigors, jerking with fever?
lBreath-holding attacks?
§Careful examination
lpresence of fever?
levidence of URTI, otitis or tonsillitis, MENINGITIS,
GE, septic arthritis, UTI?

46. 05/29/09 SHO INDUCTION/DR.S.SEN 46
SIMPLE FEBRILE CONVULSIONS
§At age of 6 months-5 years
§Generalized
§Loss of consciousness
§No focal features
§No serious perinatal problems, previous illness
or head injuries
§Short lasting (< 20 minutes)

47. 05/29/09 SHO INDUCTION/DR.S.SEN 47
FEBRILE FIT- INVESTIGATIONS
> 1 year old
lIf recovered from fit, can rely on clinical REVIEW
lIf obvious source of infection, investigate as
appropriate
lIf no obvious source, do MSU and continue REVIEW
lIf child is getting worse, do LP
<1 year old:
lMuch lower threshold for full investigations,
including LP, blood cultures, CXR, MSU
lIf the child is ill, especially one with signs of
meningitis start iv antibiotics immediately (cultures)

48. 05/29/09 SHO INDUCTION/DR.S.SEN 48
FEBRILE FIT - TREATMENT
FEVER: take off clothes, give paracetamol, use fan
FITS: rectal Diazepam 2.5 mg < 1 year and 5 mg > 1 year
INFECTION: antibiotics if not for viral URTI
ADVICE TO PARENTS (fact sheet)
PROLONGED FIT:
Diazepam IV 0.25 - 0.3 mg/kg. (250 - 300 mcg/kg) slowly
Phenobarbitone (after 15 mins) IV 10 mg/kg slowly
Phenytoin IV (cardiac monitor!) 10 mg/Kg slowly
Paraldehyde PR 0.4 ml/kg + equal volume of araechis oil
IM 1 ml/yr (maximum 10 ml)10 mins

49. 05/29/09 SHO INDUCTION/DR.S.SEN 49
DKA - SYMPTOMS
Êhigh blood glucose >16mmol/l
Ësignificant dehydration >5%
Ìacidotic pH < 7.3 and bicarbonate < 15
Íheavy ketonuria
Îimpaired level of consciousness

50. 05/29/09 SHO INDUCTION/DR.S.SEN 50
CLINICAL ASSESSMENT OF HYDRATION
Deficit should not be overestimated with traditional
5,10,15%! (Mismanagement might start here!)
ïAlert: mild 3% dehydration (only oral rehydration)
ïThirsty, lethargic: moderate 6% dehydration (iv rehydr.)
èDrowsy or comatose child with low or unrecordable
blood pressure has severe 10% dehydration, requiring
immediately 20ml/kg 4.5% plasma (given in 15-60 mins,
depending on BP)

51. 05/29/09 SHO INDUCTION/DR.S.SEN 51
ASSESSMENT OF DEHYDRATION
MILD MODERATE SEVERE
Wt loss 3(5)% 6(9)% 10% or more
General thirsty thirsty, irritabledrowsy/ coma
Turgor normal retracts slowlywrinkles
Eyes normal sunken absent tears
Mucosa moist dry very dry
RR normal rapid and weakrapid and deep
Pulse normal rapid and weakimpalpable
Cap.refillnormal < 3 sec > 3 sec
BP normal normal or lowunrecordable
Urine flownormal reduced, darkoliguria/ anuria
Deficit 30(50) ml/kg60(90)ml/kg 100 ml/kg

52. 05/29/09 SHO INDUCTION/DR.S.SEN 52
DKA - INITIAL INVESTIGATIONS
Blood: glucose (BM stix is usually lower),
FBC, culture, pH and bicarbonate
U+ E+ osm.
Urine: glucose and ketones, C+ S
Arterial or capillary blood gases if venous pH<7.0
CXR
Calculate osmolality: 2(Na+K) + glu + urea

53. 05/29/09 SHO INDUCTION/DR.S.SEN 53
DKA - IMMEDIATE MONITORING
uvital signs: RR, HR, BP. temp
ubody weight (estimate on 50th centile, last clinic weight)
ublood glucose hourly until acidosis resolved
uU+E 6 hourly, urine ketones and glucose 2-4 hourly
ufluid flow-chart (input, output, ongoing losses (aspirate)
uoxygen saturation
uneurological observation to detect cerebral oedema

54. 05/29/09 SHO INDUCTION/DR.S.SEN 54
DKA - IMMEDIATE MANAGEMENT
§ESTABLISH IV ACCESS:
lgive initially 10-20ml/kg plasma or 4.5% albumin
over one hour or within 15-30 mins to restore BP
lgive normal 0.9% saline until BG is >15 mmol/l
§PASS NGT AND/OR BLADDER CATHETER
¨if the child is unconscious,
¨not passing urine, vomiting or
¨presenting with abdominal distension
¨CONSIDER IV ANTIBIOTICS

55. 05/29/09 SHO INDUCTION/DR.S.SEN 55
DKA REHYDRATION
What do you want to give?
§Albumin 4.5% for the start if BP is low (10-20 ml/ kg)
§Normal, isotonic 0.9% saline without potassium until
blood glucose >15mmol/l
§4% dextrose / 0.18% saline with 20 mmol /500ml
potassium, when blood glucose <15 mmol/lif serum
potassium is <6 mmol/l and urine output is present
§Bicarbonate supplementation rarely if ph < 7.1
give half of the calculated dose (1/3 x wt x BE)

56. 05/29/09 SHO INDUCTION/DR.S.SEN 56
DKA - REHYDRATION
How much do you want to give?
Estimate the degree of dehydration on the clinical signs
Calculate expected weight on 50th centile
Calculate total loss and required volume of total
rehydration: deficit + added daily maintenance
Maximum fluid is limited to 4.0 litre / m2 / 24hrs
ÞMild dehydration: oral 30ml/kg deficit + daily maint.
ÞModerate: iv 60 ml/kg fluid deficit + daily maint.
èSevere dehydration: 20ml/kg plasma in 15-30-60 mins,
followed by iv 100ml/kg deficit + daily maint.

57. 05/29/09 SHO INDUCTION/DR.S.SEN 57
DKA - VOLUME OF REHYDRATION
DEFICIT
to be replaced in 24 or 36 or 48 hrs
DAILY MAINTENANCE
TO BE ADDED DAILY
Age WtDehydr. Deficit Body weightMaintenance fluid
for first 10 kgs add 100mls/kg/24hrs
1yr10 kgs 10%
6%
3%
1000 mls
600 mls
300 mls
from 10 to 20 kgsadd 50 mls/kg/24hrs
5yrs18 kgs 10%
6%
3%
1800 mls
1000 mls
500 mls
over 20 kgs add 25 mls/kg/24 hrs
10yrs30 kgs 10%
6%
3%
3000 mls
1800 mls
900 mls
15yrs50 kgs 10%
6%
3%
5000 mls
3000 mls
1500 mls

58. 05/29/09 SHO INDUCTION/DR.S.SEN 58
DURATION OF REHYDRATION
Depending on osmolality:
§over 24 hrs if normosmolality (280 mosm)
§over 36 hrs if hyperosmolality > 340
§over 48 hrs if hyperosmolality > 400
Reassess fluid requirement 4 hourly and add any
accumulated negative balance (urine loss, vomiting,
gastric aspirate etc)
Treat cerebral oedema immediately
·with reduction of rate of fluid administration and
·with iv mannitol 0.25 -1.0gm/kg/dose over 30 mins

59. 05/29/09 SHO INDUCTION/DR.S.SEN 59
DKA - INSULIN TREATMENT
Aim: slow reduction of hyperglycaemia (2.5mmol/hr) and
maintainance of normoglycaemia (4-8 mmol/l)
Initial dose of intravenous insulin infusion:
0.1unit / kg / hr of soluble Humulin S or Actrapid (use 50
units/50 ml saline) NEVER GIVE SC STAT DOSE!
Reduce iv insulin infusion to 0.05 unit/kg/hr, when blood
glucose falls to 10-15 mmol /l
Increase to 0.15unit/kg/hr if acidosis persists (pH < 7.0)
Replace iv sliding scale with sc insulin asap

60. 05/29/09 SHO INDUCTION/DR.S.SEN 60
SLIDING SCALE FOR SOLUBLE INSULIN
Blood glucose
mmol/kg
Infusion
unit/kg/hour
Sc sliding
4- 6 hourly
unit/kg/dose
10 -15 0.05 0.10
15 -20 0.10 0.15
>20 0.15 0.20

61. 05/29/09 SHO INDUCTION/DR.S.SEN 61
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