Paediatric Emergencies

PAEDIATRIC EMERGENCIES : 

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

PAEDIATRIC EMERGENCIES : 

10/29/2009 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

PAEDIATRIC EMERGENCIES : 

10/29/2009 SHO INDUCTION/DR.S.SEN 3 PAEDIATRIC EMERGENCIES 4. INFECTIONS Meningitis Encephalitis Kawasaki HUS Pertussis Endocarditis 5. SEIZURES Status epilepticus Febrile fits Hypsarrhythmia Non febrile fits Increased intracranial pressure

PAEDIATRIC EMERGENCIES : 

10/29/2009 SHO INDUCTION/DR.S.SEN 4 PAEDIATRIC EMERGENCIES 6. RENAL Hypertension Haematuria UTI Nephrosis HUS 7. SKIN Rash, Erythema Purpura, Petechia Peeling Vesicles, Pustula Cellulitis NAI

PAEDIATRIC EMERGENCIES : 

10/29/2009 SHO INDUCTION/DR.S.SEN 5 PAEDIATRIC EMERGENCIES 8. PAINS Limping child Chest pain Abdominal pain Headache Backache Sickle Cell 9. ENVIRONMENTAL Burns, smoke inhalation Drowning Poisoning Hypothermia, heat stress Anaphylaxis Head injury and RTA NAI and SA

EMERGENCIES IN BABIES : 

10/29/2009 SHO INDUCTION/DR.S.SEN 6 EMERGENCIES IN BABIES Excessive crying Not feeding Cyanosis Apnoea Jaundice Fitting Diarrhoea Vomiting Fever Bleeding

COMA : 

10/29/2009 SHO INDUCTION/DR.S.SEN 7 COMA STATE OF UNRESPONSIVENESS DUE TO DIFFUSE LESIONS OF HEMISPHERES / BRAIN STEMS Structural lesions bleeding, tumour, abscess, hydrocephalus Non-structural lesions (95%) seizures, drugs / poisons infection (meningitis, encephalitis, HUS) metabolic (hypoglycaemia, DKA, Reye) renal failure, hepatic coma endocrine (Addison)

COMA: ASSESSMENT AND DIAGNOSIS : 

10/29/2009 SHO INDUCTION/DR.S.SEN 8 COMA: ASSESSMENT AND DIAGNOSIS Rapid History and General Examination Skin (trauma, petechiae, bleeding) Sutures in infant and neck stiffness, systemic, AF CNS examination GCS, Gag R, Blinking Pupils, Reaction, EOM Palsy, Fundi, Dolls Eye Motor- Posture, Tone, Symmetry/Lateralizing signs Reflexes- DTR, Plantars Pain, Grimace, Flexion, Extension, None Assess level of Central Dysfunction

CHILDREN’S COMA SCORE (15) : 

10/29/2009 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

MANAGEMENT OF COMA : 

10/29/2009 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 Give high flow oxygen, if breathing Ventilate with bag and mask Intubate with Anaesthetist, if breathing inadequate / GCS 8 / herniation syndromes Circulation - monitor BP, CRT, PR iv access: 2 venous and arterial lines

INVESTIGATIONS IN COMA : 

10/29/2009 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

TREATMENT OF COMA : 

10/29/2009 SHO INDUCTION/DR.S.SEN 12 TREATMENT OF COMA Treat Shock - Restore and control BP Treat The Treatable Maintain BS with 10% dextrose 5mls/kg PRN Restricted fluid (document type & rate) Mannitol, if increased intracranial pressure Consider Cefotaxime, Acyclovir, Erythromycin Consider Flumazenil, Naloxone, Anticonvulsant May require transfer to PICU

SHOCK : 

10/29/2009 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

1. HYPOVOLAEMIC SHOCK : 

10/29/2009 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

2. SEPTIC (DISTRIBUTIVE) SHOCK : 

10/29/2009 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

3.OBSTRUCTIVE SHOCK : 

10/29/2009 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

4.CARDIOGENIC SHOCK : 

10/29/2009 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

ASSESSMENT OF SHOCK : 

10/29/2009 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 Children can compensate for hypoperfusion states Hypotension is a late sign of decompensated shock

EARLY AND LATE SHOCK : 

10/29/2009 SHO INDUCTION/DR.S.SEN 19 EARLY AND LATE SHOCK tachycardia  bradycardia, dysrhytmia tachypnoea  severe tachypnoea and gasping low pulse pressure  hypotension cool extremities, decreased CR  absent peripheral pulses dry mucosa  mild oliguria  severe oliguria  anuria restlessness / agitation  unconsciousness

GENERAL MANAGEMENT OF SHOCK : 

10/29/2009 SHO INDUCTION/DR.S.SEN 20 GENERAL MANAGEMENT OF SHOCK MONITOR: HR, BP, BP (CVP), O2 sat., fluid balance AIRWAY, BREATHING, CIRCULATION Reverse hypoxia and acidosis Control bleeding with direct pressure Obtain intravenous (arterial) access INVESTIGATIONS: FBC, U+E+osm, LFT (fibr, glu), BG, BC, clotting, BG MSU, X-ray, ECG, Brain scan TRANSFER TO ITU: no response to Dopamine 2-20ugm/kg/min signs of organ failure

SPECIFIC MANAGEMENT OF SHOCK : 

10/29/2009 SHO INDUCTION/DR.S.SEN 21 SPECIFIC MANAGEMENT OF SHOCK Hypovolaemia: rapid volume replacement Septic shock: antibiotics and inotropes Cardiogenic shock: minimal volume support Inotropes (Dopamin, Dobutamine), if low BP+high HR Chronotropes (Isoproterenol or Epinephrine), if low BP + bradycardia or normal heart rate Obstructive shock: drainage Anaphylaxis: oxygen, adrenalin, hydrocortisone

RESPIRATORY FAILURES : 

RESPIRATORY FAILURES Upper Airway Obstruction Asthma (see BPA guideline)

ASTHMA ASSESSMENT : 

10/29/2009 SHO INDUCTION/DR.S.SEN 23 ASTHMA ASSESSMENT

ASTHMA TREATMENT : 

10/29/2009 SHO INDUCTION/DR.S.SEN 24 ASTHMA TREATMENT NEBULISERS (use oxygen): Salbutamol: 5mg Atrovent 250 ugm STEROIDS: prednisolone 2mg/kg/day (max 40) hydrocortisone: 4mg/kg 6 hourly AMINOPHYLLINE (with paediatricians): loading dose: 5mg/kg maint. 1mg/kg/hour (max 20mg/kg/day)

SYMPTOMS OF CROUP : 

10/29/2009 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

CROUP - ASSESSMENT : 

10/29/2009 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

CROUP - MANAGEMENT : 

10/29/2009 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  severe croup: STRIDOR AT REST, recession and tachypnoea  HYPOXIA, stridor, tachycardia, decreased breath sounds Keep calm and nurse in warm room, in upright position Oxygen if oxygen saturations <92% Budesonide (Pulmicort) 2mg nebulised Dexamethasone (single dose) 0.6mg/kg Adrenaline (1:1000) 0.5mls nebulised with 5mls saline repeat 0.5mls/kg (max. dose 5mls)

CROUP - CRITERIA FOR ADMISSION : 

10/29/2009 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)

EPIGLOTTITIS : 

10/29/2009 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)

EPIGLOTTITIS - MANAGEMENT : 

10/29/2009 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

MENINGOCOCCUS INFECTION CLINICAL SIGNS : 

10/29/2009 SHO INDUCTION/DR.S.SEN 31 MENINGOCOCCUS INFECTION CLINICAL SIGNS Suspect in any child with sudden onset of fever with headache, vomiting, stiff neck or pain in neck, petechial rash ( non blanching) Other features include photophobia, drowsiness or confusion and signs of meningism A rapidly evolving red macular rash may precede the typical petechial rash

MENINGOCOCCAL INFECTION MANAGEMENT : 

10/29/2009 SHO INDUCTION/DR.S.SEN 32 MENINGOCOCCAL INFECTION MANAGEMENT Patients with meningococcal infection should be rapidly assessed in resuscitation room Monitor HR, BP, O2 saturation, respiratory rate Act on A.B.C. of resuscitation if required Further management depends on general condition

MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTION Relatively Well Child : 

10/29/2009 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

MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTIONUnstable Child : 

10/29/2009 SHO INDUCTION/DR.S.SEN 34 MANAGEMENT OF SUSPECTED MENINGOCOCCAL INFECTIONUnstable 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

MANAGEMENT OF SEVERE MENINGOCOCCAL INFECTION: Early selection for transfer to PICU : 

10/29/2009 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

CHILDREN’S COMA SCORE (15) : 

10/29/2009 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

STATUS EPILEPTICUS - MANAGEMENT : 

10/29/2009 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

DRUGS IN STATUS EPILEPTICUS : 

10/29/2009 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)

COMPARISON OF DRUGS FOR STATUS : 

10/29/2009 SHO INDUCTION/DR.S.SEN 39 COMPARISON OF DRUGS FOR STATUS

FURTHER DRUGS IN STATUS : 

10/29/2009 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

NON-FEBRILE CONVULSION : 

10/29/2009 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) intracranial space occupying lesions hypertensive encephalopathy metabolic disturbance (hypoglycaemia, hypocalcaemia) inborn errors of metabolism congenital and inherited disorders (TS) History (prenatal and natal) and examination Monitoring (pulse oximetry)

NON-FEBRILE CONVULSION: INVESTIGATIONS : 

10/29/2009 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

JITTERY OR FITTING BABY? : 

10/29/2009 SHO INDUCTION/DR.S.SEN 43 JITTERY OR FITTING BABY?

FITTING BABIES: MANAGEMENT : 

10/29/2009 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)

FEBRILE FIT - ASSESSMENT : 

10/29/2009 SHO INDUCTION/DR.S.SEN 45 FEBRILE FIT - ASSESSMENT Accurate history of event Any preceding illness, including fever Funny turns, rigors, jerking with fever? Breath-holding attacks? Careful examination presence of fever? evidence of URTI, otitis or tonsillitis, MENINGITIS, GE, septic arthritis, UTI?

SIMPLE FEBRILE CONVULSIONS : 

10/29/2009 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)

FEBRILE FIT- INVESTIGATIONS : 

10/29/2009 SHO INDUCTION/DR.S.SEN 47 FEBRILE FIT- INVESTIGATIONS > 1 year old If recovered from fit, can rely on clinical REVIEW If obvious source of infection, investigate as appropriate If no obvious source, do MSU and continue REVIEW If child is getting worse, do LP <1 year old: Much lower threshold for full investigations, including LP, blood cultures, CXR, MSU If the child is ill, especially one with signs of meningitis start iv antibiotics immediately (cultures)

FEBRILE FIT - TREATMENT : 

10/29/2009 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

DKA - SYMPTOMS : 

10/29/2009 SHO INDUCTION/DR.S.SEN 49 DKA - SYMPTOMS high blood glucose >16mmol/l significant dehydration >5% acidotic pH < 7.3 and bicarbonate < 15 heavy ketonuria impaired level of consciousness

CLINICAL ASSESSMENT OF HYDRATION : 

10/29/2009 SHO INDUCTION/DR.S.SEN 50 CLINICAL ASSESSMENT OF HYDRATION Deficit should not be overestimated with traditional 5,10,15%! (Mismanagement might start here!) Alert: mild 3% dehydration (only oral rehydration) Thirsty, lethargic: moderate 6% dehydration (iv rehydr.) Drowsy 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)

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DKA - INITIAL INVESTIGATIONS : 

10/29/2009 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

DKA - IMMEDIATE MONITORING : 

10/29/2009 SHO INDUCTION/DR.S.SEN 53 DKA - IMMEDIATE MONITORING vital signs: RR, HR, BP. temp body weight (estimate on 50th centile, last clinic weight) blood glucose hourly until acidosis resolved U+E 6 hourly, urine ketones and glucose 2-4 hourly fluid flow-chart (input, output, ongoing losses (aspirate) oxygen saturation neurological observation to detect cerebral oedema

DKA - IMMEDIATE MANAGEMENT : 

10/29/2009 SHO INDUCTION/DR.S.SEN 54 DKA - IMMEDIATE MANAGEMENT ESTABLISH IV ACCESS: give initially 10-20ml/kg plasma or 4.5% albumin over one hour or within 15-30 mins to restore BP give 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

DKA REHYDRATIONWhat do you want to give? : 

10/29/2009 SHO INDUCTION/DR.S.SEN 55 DKA REHYDRATIONWhat 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)

DKA - REHYDRATIONHow much do you want to give? : 

10/29/2009 SHO INDUCTION/DR.S.SEN 56 DKA - REHYDRATIONHow 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 Mild dehydration: oral 30ml/kg deficit + daily maint. Moderate: iv 60 ml/kg fluid deficit + daily maint. Severe dehydration: 20ml/kg plasma in 15-30-60 mins, followed by iv 100ml/kg deficit + daily maint.

DKA - VOLUME OF REHYDRATION : 

10/29/2009 SHO INDUCTION/DR.S.SEN 57 DKA - VOLUME OF REHYDRATION

DURATION OF REHYDRATION : 

10/29/2009 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

DKA - INSULIN TREATMENT : 

10/29/2009 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

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