#SimBlog: Through the Candy Cane Forest
“A 2-year-old boy is brought to the ED by his mum with fast breathing and vomiting...”
Observations
A – Patent, crying
B – RR 40, sats 97% in air, deep breathing
C – HR 150, CRT <2sec, BP 100/60
D – A on AVPU scale, BM reads high
E – Temp 37°C
Clinical Findings
Chest clear
Dry lips and mouth
Blood ketones 6 on bedside monitor
Why We Simulated
A systematic review published in the BMJ in 2011 [1] explored the presentation of Type 1 diabetes mellitus in children and young adults with diabetic ketoacidosis (DKA) at diagnosis.
(click for PDF version)
46 studies were included, involving more than 24,000 children in 31 countries. Findings which are highly relevant to those of us working in the paediatric ED are:
The mean duration of symptom before the child presented in DKA was 16.5 days. Those presenting with hyperglycaemia without DKA had a mean symptom duration of 17.1 days.
Up to 38.8% of children who presented with DKA had been seen by at least 1 doctor before diagnosis.
These two figures are important because the child's symptoms may often have been put down to another illness by the parent/GP and it is, therefore, our role in the ED to explore these recent symptoms in more detail and have a low threshold for testing a bedside blood glucose.
Acute management of a child presenting in DKA involves careful attention to weight-based IV fluid calculations and ensuring these fluids are running for 1-2 hours before the insulin infusion is commenced. Such calculations are often practised rarely and so we conducted this simulation to ensure our team were well practised for the next real life situation.
References:
- Juliet A Usher-Smith et al. BMJ 2011: Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review
Further Reading:
- University Hospitals of Leicester Children's Medical Guideline: Paediatric Management of Diabetic Ketoacidosis (DKA)
- British Society for Paediatric Endocrinology and Diabetes: Paediatric DKA Calculator - will need to download onto desktop and run outside web browser
Learning Points
There are very few situations where it is impossible to physically weigh a child – do so whenever possible. It can be very beneficial in planning IV fluid regimes.
Print out and follow the DKA guideline for management – fluid calculations are fully explained within our guideline.
Be honest with the parents and explain the diagnosis of diabetes early. Further details can be given once the child is more stable but it is important they understand why their child is sick.
Positive Feedback
Recognised tachypnoea early as a sign of possible DKA and performed blood glucose and ketone testing by the bedside to confirm diagnosis.
Nurse and doctor worked through fluid calculations together to ensure figures were correct.
Planned for ongoing care requirements including referral to HDU after establishing initial treatment plan.
