A Primer on Pediatric Diabetic Emergencies

Insulin is essential for the body to process carbohydrates (sugars), but is also needed for the body to deal effectively with fat and protein metabolism. Insulin reduces blood glucose levels by permitting the glucose to enter muscle cells and by stimulating the conversion of glucose to glycogen that can be stored in the body. Insulin also slows the release of stored glucose from glycogen stores in the liver and slows the breakdown of fat to triglycerides, free fatty acids and ketones.

Hyperglycemia results when insulin deficiency leads to uninhibited production of glucose and prevents the utilization of this circulating glucose. The overabundance of glucose in the blood leads to an increase of glucose in the urine. This excess glucose in the urine causes an increase in total urine production (polyurea). The person becomes dehydrated, and that leads to increased thirst (polydipsia). Fat and protein breakdown occurs, leading to the formation of ketones. If left untreated, the child wastes away and develops diabetic ketoacidosis (DKA), which may be fatal.

When there is too much insulin in the body, there is a decrease in the release of glucose, leading to low blood sugar levels (hypoglycemia). This process can be very detrimental since glucose is the only source of energy for red blood cells, the interior portion of the kidney and the brain. Without glucose, brain cells will begin to die relatively quickly.

The incidence of diabetes in children increases with age until mid puberty and then declines, but type 1 diabetes can occur at any age. The disease may even appear in the first year of life, although this is unusual. Almost all degrees of disease severity may be present in the child. Symptoms may be minimal or immediately life-threatening, subtle or dramatic.

Prehospital Management

The acute complications of type 1 diabetes are emergency conditions that can lead to life-threatening situations for the patient. The two primary complications that can affect the diabetic patient are hypoglycemia and hyperglycemia, which may lead to diabetic ketoacidosis. Since they are treated differently, we should discuss them separately. Remember that in all cases, a complete set of vital signs should be obtained and recorded on the patient run sheet.

Hypoglycemia—The development of hypoglycemia in children with diabetes is the more common complication and is sometimes referred to as an insulin reaction. The cause of hypoglycemia in the diabetic child is that the child has either been given too much insulin or has not taken in an adequate amount of glucose to balance the insulin dose. Another situation which may arise is when the child engages in strenuous exercise. This exercise will burn much of the glucose present in the body. In these situations, the insulin dose prior to the exercise should be decreased.

Generally, as the glucose level in the blood decreases below 70 mg/dL, immediate treatment is required. Patients with prior experiences may have detected the drop in their blood sugar levels and ingested sugar-containing foods prior to your arrival. Many patients, in an effort to prevent episodes of hypoglycemia, keep sugar-containing snacks with them at all times. Their symptoms may include shakiness, hunger, nervousness, sweating, dizziness, sleepiness, confusion, anxiety or weakness. In fact, they may be unresponsive.

Once you have determined that hypoglycemia is present, the goal of therapy is to rapidly restore the blood sugar level toward normal. While attempting to establish an IV line, glucagon may be given by the intramuscular route. If this is not successful or inadequate, administer IV dextrose. The dosage and concentration of the solution can vary depending on the patient’s age. In the very young, 10% dextrose is the treatment of choice. In the next-oldest group, 25% dextrose is utilized. The oldest group of children receives 50% dextrose, as does the adult population. Familiarize yourself with the protocols in your region, since variations exist.

Diabetic ketoacidosis—Development of diabetic ketoacidosis, while less common than hypoglycemia, is more likely in the patient with type 1 diabetes. Failing to adequately treat this condition can lead, in time, to coma and death. These patients usually have increased thirst, dry mouth, frequent urination, nausea and vomiting, abdominal pain, dry or flushed skin, confusion, a fruity odor on the breath, rapid respirations (tachypnea) and elevated blood glucose levels. On occasion, patients with this condition may develop fever. The onset of DKA is gradual, and almost all patients with it require hospitalization.