Episode 63 – Pediatric DKA

Pediatric DKA was identified as one of key diagnoses that we need to get better at managing in a massive national needs assessment conducted by the fine folks at TREKK – Translating Emergency Knowledge for Kids – one of EM Cases’ partners who’s mission is to improve the care of children in non-pediatric emergency departments across the country. You might be wondering - why was DKA singled out in this needs assessment?

It turns out that kids who present to the ED in DKA without a known history of diabetes, can sometimes be tricky to diagnose, as they often present with vague symptoms. When a child does have a known history of diabetes, and the diagnosis of DKA is obvious, the challenge turns to managing severe, life-threatening DKA, so that we avoid the many potential complications of the DKA itself as well as the complications of treatment - cerebral edema being the big bad one.

The approach to these patients has evolved over the years, even since I started practicing, from bolusing insulin and super aggressive fluid resuscitation to more gentle fluid management and delayed insulin drips, as examples. There are subtleties and controversies in the management of DKA when it comes to fluid management, correcting serum potassium and acidosis, preventing cerebral edema, as well as airway management for the really sick kids. In this episode we‘ll be asking our guest pediatric emergency medicine experts Dr. Sarah Reid, who you may remember from her powerhouse performance on our recent episodes on pediatric fever and sepsis, and Dr. Sarah Curtis, not only a pediatric emergency physician, but a prominent pediatric emergency researcher in Canada, about the key historical and examination pearls to help pick up this sometimes elusive diagnosis, what the value of serum ketones are in the diagnosis of DKA, how to assess the severity of DKA to guide management, how to avoid the dreaded cerebral edema that all too often complicates DKA, how to best adjust fluids and insulin during treatment, which kids can go home, which kids can go to the floor and which kids need to be transferred to a Pediatric ICU.



Written Summary & blog post by Dr. Michael Kilean, edited by Dr. Anton Helman, April 2015

Cite this podcast as: Helman, A, Reid, S, Curtis, S. Pediatric DKA. Emergency Medicine Cases. April, 2015. https://emergencymedicinecases.com/pediatric-dka/. Accessed [date].

Why can Pediatric DKA be easy to miss?

In a child without a known history of diabetes, making the diagnosis of DKA can be difficult, especially in the mild cases where symptoms can be quite vague. If we don’t have a high level of suspicion we can easily miss cases of early DKA. Thus, the diagnosis should be considered or ruled out if any of the following are present:



* Abdominal pain

* Isolated vomiting

* Polyuria or polydipsia

* Fatigue

* Headaches

* Known diabetes

* Specific high risk groups (ie. Teenagers, children on insulin pumps and those from lower socio-economic status).



Remember that glucose should be considered the sixth vital sign and any “sick” appearing child should have a point of care glucose done!

Once DKA is suspected, elements on history should focus on screening for symptoms of diabetes (polyuria, polydipsia, enuresis ,weight loss) as well as symptoms of DKA (nausea, vomiting, abdominal pain, decreased alertness). However, be sure to take the assessment one step further and consider any precipitating causes (viral or bacterial illness, social factors etc).

Important Pathophysiology of DKA

DKA is most commonly seen in patients with type 1 diabetes since the disease is defined by insulin deficiency.