Diabetic ketoacidosis (DKA) is one of the most common causes of morbidity and mortality in new-onset type 1 diabetes (T1D). Supraventricular tachycardia (SVT), however, is a very rare complication of DKA. We present the case of a patient with new-onset T1D who presented with DKA. He received intravenous fluid resuscitation, insulin and potassium supplementation and subsequently developed SVT, confirmed on a 12-lead electrocardiograph despite a structurally normal heart. Vagal manoeuvres and adenosine failed to restore sinus rhythm, but flecainide was successful. We conclude that SVT can occur as a complication of DKA, including in new-onset T1D. Our case is the first of this phenomenon occurring in new-onset childhood diabetes, as the few prior documented cases had established diabetes. Furthermore, a combination of potassium derangement, hypophosphataemia and falling magnesium levels may have precipitated the event.

Diabetic ketoacidosis (DKA) is one of the most common causes of morbidity and mortality in new onset type 1 diabetes mellitus (T1DM). Children have a higher rate of neurological complications from DKA when compared to adults. The differential for sudden focal neurological deterioration in the setting of DKA is cerebral oedema followed by ischaemic and haemorrhagic stroke. Spontaneous intracranial haemorrhages can present with non-specific features frequently, for example, impaired consciousness, even when biochemical parameters are improving in the setting of DKA. We report the case of a girl with new onset T1D who presented in severe DKA and subsequently developed intracerebral parenchymal and subarachnoid haemorrhages. Our patient is unique in that no focal neurological or neuropsychological deficits have been found at 1-year follow up, compared to the literature which suggests poor outcomes. Our case contrasts with these previous cases as none of the other case reports demonstrated subarachnoid haemorrhages with survival.

What you see is not what you getIn some chronic or variable conditions, a child can seem to respond to a medicine which, in trial conditions, makes no meaningful improvement. These 'responders' are continued on the therapy as 'it works for them'. There is a concrete reality which crashes against the 'evidence' and our eyes link to our hearts more strongly than a serpiginously written paper does.There are a bunch of these which you might have come across, especially if you have been around for a while. Steroids and bronchodilators in bronchiolitis. Hormone modulation in muscular dystrophies. Cannabidiol for almost anything. Very occasionally, we are seeing a true 'null average' which splits into those whose disease is worsened by a treatment, and those in whom it is improved. But what is mostly happening seems to be the same process as the teaspoon in the champagne bottle.A very long time ago, sparkling wines were rarely drunk, and often not in a single evening, and to 'keep the fizz', the bottle was refrigerated with a teaspoon poking down the neck. The next day, the fizz was (just) there. The teaspoon had worked. Of course, the same effect would be found by the fridge and bottle without a teaspoon… but when you have something that works why try to break it? What we are frequently not seeing or remembering is those who got better, or did not fade as fast as we expected, in whom we did not act with the treatment.Just like with the street magician, we need to be aware of what we are not seeing as much as what we are. The process of critical appraisal is not designed just to annoy our clinician wants, but keep our hope in check.

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