Clinical assessment

The clinical features of diabetic ketoacidosis are shown in Table 2.2.

Table 2.2 Clinical features of diabetic ketoacidosis in children

Symptoms Signs

Table 2.2 Clinical features of diabetic ketoacidosis in children

Symptoms Signs

Polyuria

Lethargy

Thirst, polydipsia

Dehydration

Rapid weight loss

Blood pressure normal, rarely low

Abdominal pain

Kussmaul respiration, or later depressed

Weakness

Smell of ketones on breath

Vomiting

Temperature normal

Air hunger

20% disordered consciousness

Confusion, coma

10% unconscious

1. During the resuscitation phase a rapid clinical assessment should have been made of the following.

• Airway, breathing and circulation. See above.

• Conscious level. If the conscious level is impaired, or there is any change in neurological status during treatment, the Glasgow Coma Score should be serially recorded, and deteriorating conscious level treated as an emergency (see section on cerebral oedema below).

• Degree of dehydration. It has recently been recognised that the degree of dehydration in children is often over-estimated by clinical methods, and that signs such as loss of skin turgor or elasticity occur at around three per cent dehydration, and not at five per cent as is often quoted. Capillary refill time, tested by applying digital pressure, may be a useful technique for the assessment of dehydration in small children, as long as they are not exposed to a cold environment.

• Weight of child. This is crucial to the fluid management, therefore every effort should be made to weigh the child. If this is not possible because of the clinical condition, use the most recent clinic weight as a guideline, or an estimated weight from centile charts.

2. Full clinical assessment can be deferred until the child has been resuscitated. Attending doctors and nurses should be aware of the following.

• Abdominal pain is a frequent accompaniment of diabetic ketoacidosis in children; a surgical emergency should not be assumed until a period of rehydration and insulin and electrolyte replacement has been allowed.

• Pyrexia is not a feature of uncomplicated ketoacidosis, and a source of infection should be sought if it is present.

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