Diabetic emergencies in children

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10.2 Diabetic emergencies in children

1 Diabetes mellitus is one of the most common chronic diseases in childhood.

2 The incidence of childhood diabetes has been increasing over the last decade.

3 Diabetic ketoacidosis is defined as BGL >11 mmol L⁻¹, pH < 7.3 and bicarbonate <15 mmol L⁻¹.

4 As obesity becomes more prevalent in childhood, type II diabetes has started to present in younger and younger adolescents.

5 Type I diabetes remains the major (>90%) cause of childhood diabetes.

Diagnosis

The classic symptoms of polyuria, polydipsia and weight loss may be present for a few weeks before parental concern is raised.

The diagnosis should be confirmed by a random blood glucose level (BGL >11 mmol L^–1) in addition to urine analysis for glucose and ketone.

Once the diagnosis is confirmed, initial management is dictated by the severity of dehydration, presence of shock, degree of acidosis, hyperglycaemia and osmolality.

In a child with no past history of diabetes the initial diagnosis may be misled by non-specific symptoms such as abdominal pain, weight loss, drowsiness, fever, secondary enuresis and dyspnoea. Beware of tachypnoea due to metabolic acidosis, intercurrent infection in a new diabetic, abdominal pain related to diabetic ketoacidosis (DKA) and drowsiness in a child. In such children, diabetes should be excluded as a possible cause with a random blood glucose.

Diabetic ketoacidosis

Diabetic ketoacidosis is the major cause of mortality in diabetic children. It often presents in newly diagnosed type I diabetic children. In established diabetics, it occasionally presents in the midst of intercurrent febrile illness or poor adherence to management.

Diabetic ketoacidosis is caused by insulin deficiency, leading to hyperglycaemia, osmotic diuresis, hyperosmolar dehydration, lipolysis, ketosis and acidosis. It may be defined by the combination of:

• hyperglycaemia;

• ketosis and ketonuria;

• acidosis (pH < 7.3, bicarbonate <15);

• dehydration and/or shock.

Management starts with rapid assessment, resuscitation and meticulous replacement of fluid, electrolyte and insulin infusion.

Like all medical emergencies, assessment of airway, breathing and circulation (ABC) is vital. Ketotic breath, degree of tachypnoea and respiratory distress should be noted. Degree of shock or dehydration should be assessed. Initial level of consciousness should be noted, and hourly neurological observation commenced. It is also important to look for a focus of infection and sepsis.

Initial investigations should include venous blood glucose, electrolytes, urea, creatinine, full blood count, venous or arterial blood gases. In addition, if sepsis is suspected, blood culture, urine culture and chest X-ray may be considered.

Resuscitation

Intravenous access should be established; ideally with two intravenous (IV) cannulae so that further venous sampling of BGL and electrolyte may be undertaken easily.

In children with shock, noted to be hypotensive and poorly perfused, resuscitation should start immediately with facial mask oxygen and intravenous fluid bolus. Normal saline (0.9% Na Cl) 10 mL kg^–1 should be given as a bolus. The normal saline bolus (10 mL kg^–1) should be repeated if the child remains shocked upon reassessment in 10 minutes.

Careful and frequent monitoring should continue for the next 24–48 hours. Monitoring should include all vital signs, including neurological assessment, urine output and ECG monitoring.

Fluid

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