Clinical Commander

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peds.dka.v1

Pediatric diabetic ketoacidosis (DKA)

pediatricsacutepediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

NEW pediatric dossier — no manifest / atoms / package on disk yet (manifest field intentionally empty). NEXT STEPS: (1) author manifest at prisma/seed/manifests/peds.dka.v1.ts; (2) RxCUI validation for insulin variants, KCl, KPhos, mannitol, hypertonic saline (some hypertonic saline RxCUIs variable); (3) calculator gaps — pediatric DKA severity calc, cerebral edema risk score, Glaser criteria absent. protocol.dka.pediatric.v1 verified resident in clinical-tools-registry.ts. Cerebral-edema risk pathway explicit per ISPAD + Glaser; PECARN FLUID guides fluid posture. Sibling differentiation from endo.dka.core.v1 covers 6 features. DEEPENING 2026-05-13: Added inpatient + icu setting playbooks (previously only ed); added transitions field (ed→icu, ed→inpatient, icu→inpatient, inpatient→outpatient, inpatient→icu re-escalation). Inpatient playbook captures two-bag transition + SC overlap; ICU playbook captures cerebral edema rescue (HS 3% 5 mL/kg or mannitol 0.5-1 g/kg) and refractory acidosis management. Weight caps explicit: bolus max 20 mL/kg, MgSO4 max 2 g per peds.status_epilepticus cross-reference. Deepened 2026-05-14 (shard-5-obped-id depth-pass-1): added co-located _briefs/peds.dka.v1.depth.md (companion to existing 2026-04-27 brief) + _research-bundles/peds.dka.v1.md. Added outpatient setting playbook (post-DKA endocrine clinic — insulin titration, CGM start, DSME reinforcement, sick-day rules quiz, pump-training audit, psychosocial + mental-health screens, HbA1c at 3 mo, annual screening per ISPAD 2022 §screening + ADA 2026 §16). Added 4 severity triggers: cerebral_edema_warning_signs (life_threatening — sub-overt Cushing's triad prodrome before overt GCS drop; treats at the pre-herniation window), insulin_late_start (severe — ISPAD 2024 update insulin must follow fluid by ≥ 1 h), bicarbonate_administered (severe — Glaser 2001 OR 4.2 independent cerebral-edema risk), hypokalemia_below_3 (severe — ISPAD 2024 K+ < 3.0 hard insulin-hold criterion above the K+ < 3.5 caution). Appended 2 PMIDs (29897851 PECARN-FLUID canonical, 11172164 Glaser canonical) alongside the existing alternate-index PMIDs (29899011, 11138992) for cross-reference at next research:pubmed loop. Bumped evidence.last_reconciled to 2026-05-14. Phenotype matrix (severity × cerebral-edema-risk × new-onset/known-T1DM × age-band × precipitant — 360-cell collapsed cross-product) encoded indirectly via severity_triggers (cerebral_edema_features, cerebral_edema_warning_signs, severe_dka_pH_lt_7_10, hypokalemia_at_presentation, hypokalemia_below_3, new_onset_t1d_high_cerebral_edema_risk, rapid_glucose_drop, precipitating_infection, shock_in_dka, insulin_late_start, bicarbonate_administered) + per-setting playbook logic (ED triage, inpatient ward, PICU, outpatient endocrine). First-class TS field for phenotype matrix is schema-blocked. Bayesian linkage (pre-test priors ~ 0.5-1% baseline cerebral-edema rate, stratified to ~ 5-10% with ≥ 3 Glaser risk factors; LRs: pCO2 < 15 LR+ ~ 3-4, BUN > 25 LR+ ~ 2-3, bicarbonate-treated LR+ ~ 4-5, Cushing's triad prodrome LR+ ~ 15-20; T_treat ~ 30% post-test OR overt features; T_test ~ 10% post-test for head CT after stabilisation; T_monitor ~ 5% post-test for q30-min PICU neuro; routing edges to id.sepsis.peds.v1 / peds.aki.v1 / peds.status_epilepticus.v1) documented in _research-bundles/peds.dka.v1.md. ROS/DDx LR seed data audited by npm run audit:ros-ddx-coverage (cross-cutting; not touched by this shard). Prehospital recognition is currently encoded implicitly via existing transitions; a first-class "prehospital" DossierSetting value is schema-blocked. Edge 2006 meta-analysis PMID lookup deferred to next research:pubmed loop.

Entry points (4)

  • symptom
    Polyuria, polydipsia, weight loss in a child (ISPAD 2022)
    polyuria_polydipsia_weight_loss
  • symptom
    Tachypnoea / Kussmaul breathing in known or suspected diabetic child (ISPAD 2022)
    kussmaul_respirations
  • symptom
    Altered mental status in known or suspected diabetic child (ISPAD 2022)
    altered_mental_status_child_diabetic
  • lab_abnormality
    BG >200 mg/dL + bicarbonate <18 + ketones in a child (ISPAD 2022)
    hyperglycemia_with_acidosis_peds

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Age <5 yr is highest cerebral-edema risk; <2 yr → PICU (ISPAD 2022; Glaser 2001)
  • weightrequired
    demographic • used at CONTEXT
    All fluid + insulin + electrolyte dosing weight-based (ISPAD 2022)
  • gcsrequired
    vital • used at CONTEXT
    Baseline + serial — cerebral edema marker (ISPAD 2022)
  • sbprequired
    vital • used at CONTEXT
    Shock diagnosis (rare in DKA) (ISPAD 2022)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia + dehydration; bradycardia + HTN = cerebral edema (ISPAD 2022)
  • rrrequired
    vital • used at CONTEXT
    Kussmaul respirations for compensation (ISPAD 2022)
  • glucoserequired
    lab • used at INITIAL_WORKUP
    BG >200 = DKA criterion (ISPAD 2022; ADA 2026 §16)
  • ketones_blood_or_urinerequired
    lab • used at INITIAL_WORKUP
    Ketonemia / ketonuria criterion (ISPAD 2022)
  • bicarbonate_or_pHrequired
    lab • used at INITIAL_WORKUP
    Severity tier (ISPAD 2022)
  • potassiumrequired
    lab • used at TREATMENT
    K+ <3.5 hold insulin and replace; K+ >5.5 hold replacement (ISPAD 2022)
  • sodiumrequired
    lab • used at TREATMENT
    Pseudohyponatremia from hyperglycemia (corrected Na) (ISPAD 2022)
  • bun_creatininerequired
    lab • used at TREATMENT
    AKI marker; elevated BUN raises cerebral-edema risk (Glaser 2001)
  • phosphate
    lab • used at TREATMENT
    Replace if <1 (ISPAD 2022)
  • pCO2_in_VBGrequired
    lab • used at RED_FLAGS
    pCO2 <15 mmHg = cerebral edema risk (Glaser 2001)
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    WBC often elevated even without infection (ISPAD 2022)
  • urine_culture_blood_culture
    lab • used at INITIAL_WORKUP
    Source if febrile precipitant (ISPAD 2022)
  • precipitantrequired
    history • used at CONTEXT
    Missed insulin / pump failure / new-onset / infection (ISPAD 2022)
  • new_onset_t1drequired
    history • used at RED_FLAGS
    New onset is highest cerebral-edema risk (ISPAD 2022; Glaser 2001)

12-phase flow (12)

  1. 1FRAME
    Confirm DKA criteria (BG >200 / 11.1 mmol/L + ketonemia/ketonuria + bicarbonate <18 OR pH <7.30); severity tier (mild pH 7.20-7.30 / moderate 7.10-7.20 / severe <7.10) (ISPAD 2022)
    inputs: glucose, ketones_blood_or_urine, bicarbonate_or_pH
    advance: Diagnosis confirmed + severity assigned
  2. 2ENTRY
    Known T1D missed insulin / pump failure / new-onset / acute illness (ISPAD 2022)
    inputs: precipitant
    advance: Entry trigger captured
  3. 3CONTEXT
    Weight, age, GCS, hydration, electrolytes, infection screen (ISPAD 2022)
    inputs: weight, gcs, sbp, hr, rr
    advance: Vitals + weight + neuro baseline documented
  4. 4RED_FLAGS
    Cerebral edema features (severe HA, decline GCS, posturing, bradycardia + HTN, fixed pupil), shock (rare), AKI (ISPAD 2022; Glaser 2001)
    inputs: gcs, pCO2_in_VBG, new_onset_t1d
    advance: Cerebral edema risk profile + shock excluded
  5. 5INITIAL_WORKUP
    Fingerstick BG, ketones, iSTAT (electrolytes / pH / pCO2 / bicarbonate), CBC, cultures if febrile, IV access (ISPAD 2022)
    inputs: glucose, ketones_blood_or_urine, potassium, sodium, bun_creatinine, cbc_with_diff, pCO2_in_VBG
    actions: panel.glucose_a1c, panel.abg, panel.cbc, workup.dka_hhs, workup.pediatric_fever
    advance: Labs returned
  6. 6BRANCHING_WORKUP
    Head CT only if cerebral edema suspected (do not delay treatment for imaging) (ISPAD 2022)
    advance: Imaging only if neurological deterioration
  7. 7DIFFERENTIAL
    DKA vs HHS (pediatric HHS rare; T2DM + obesity), euglycemic DKA (SGLT2i adult), salicylate, methanol (ISPAD 2022)
    advance: Diagnosis confirmed
  8. 8RISK_STRATIFICATION
    pH-based severity; cerebral-edema risk (age <5, new-onset, pH <7.10, pCO2 <15, BUN >25) (ISPAD 2022; Glaser 2001)
    inputs: weight, pCO2_in_VBG
    advance: Severity + cerebral edema risk documented
  9. 9TREATMENT
    Step 1 fluid (NS or LR 10 mL/kg over 1 h ONLY if shock, max 20 mL/kg; routine isotonic over 48 h with deficit + maintenance); Step 2 insulin 0.05-0.1 U/kg/h IV NO bolus; Step 3 two-bag system (D10NS + saline) once BG <300; Step 4 K+ 40 mEq/L if K+ 4-5, 60 mEq/L if K+ <4 (hold if K+ >5.5); Step 5 phosphate replacement if <1; NEVER bicarbonate unless pH <6.90 with hemodynamic compromise (ISPAD 2022; Kuppermann 2018)
    inputs: weight, potassium, sodium, glucose
    actions: protocol.dka.pediatric.v1
    advance: Resuscitation + insulin + two-bag plan documented
  10. 10DISPOSITION
    PICU for severe / age <2 / cerebral edema risk; ward for moderate-stable (ISPAD 2022)
    advance: Disposition + level of care set
  11. 11MONITORING
    q1h vitals + neurochecks + BG; q2-4h iSTAT; strict I/O; cerebral edema vigilance (ISPAD 2022)
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Pediatric endocrinology, diabetes education, family sick-day rules + glucagon kit; annual screening (ADA 2026 §16; ISPAD 2022)
    advance: Endocrine follow-up + family education complete