A Primer on Pediatric Diabetic Emergencies

What do you do with a hypo- or hyperglycemic child?


Every prehospital provider can attest that the stress level on any EMS call increases dramatically when the patient is a child, especially when the child appears to be seriously ill. Most of us can empathize, since we usually have children, siblings or nieces/nephews. But our increased level of stress also occurs because pediatric emergencies account for only a very small percentage of ambulance runs. This percentage drops even further if we consider ALS pediatric calls separately. The old adage holds true: We are much better at a task when we do it repeatedly.

It is our hope that this article will help prepare you to deal with the pediatric diabetic patient in a knowledgeable and professional manner, and that this preparation will reduce the adrenaline level for prehospital responders.

Call #1

You and your partner are dispatched for a 10-year-old diabetic patient who became unresponsive at school. Upon arrival you are led to a classroom where you find the child lying on the floor, moaning softly and appearing diaphoretic. Her teacher informs you that the child is a known diabetic who takes insulin. The teacher is unaware of any additional medical issues. While you prepare to check the child’s blood sugar, your partner obtains the following vital signs: BP 98/54, pulse 96 and regular, RR 18, pulse oximetry 97%. You administer oxygen via a pediatric non-rebreather and perform a finger stick to obtain a blood sample. The glucometer reports a blood sugar of 28 mg/dL.

Your partner starts an intravenous line with minimal difficulty. You then administer 1 ampule of D25 (25% dextrose) intravenously. Shortly thereafter the child starts to awaken, seems to be confused and repeatedly asks, “What happened?” You, your partner and the teacher reassure her that everything is OK and explain that her blood sugar was too low. You then move her to the stretcher for transport to the nearby pediatric emergency department.

Call #2

You and your partner receive a call for a 5-year-old with altered mental status at her kindergarten classroom. No further history is available. When you arrive you find the child sitting in a chair, not making eye contact and not responding appropriately to questions. Her teacher is unaware of any medical conditions but says the girl had been absent the day before because of nausea and vomiting. It is obvious from her clothing that she has vomited today also. Your partner obtains vital signs: BP 96/52, pulse 102 and regular, RR 24, pulse oximetry 97%. You set up your glucometer and obtain a blood specimen from a finger stick. Her blood glucose reading is HHH.

You administer oxygen via a pediatric non-rebreather mask and start an IV of normal saline. Based on an estimate of the child’s weight, you administer a bolus of fluid at 20 ml/kg. You also apply an ECG monitor and prepare to transfer her to the nearby pediatric emergency department.

These examples help illustrate the ways pediatric diabetic emergencies tend to present. You may have a known diabetic child who becomes hypoglycemic and demonstrates a rapid onset of symptoms, or you may find a child not yet diagnosed with diabetes who slowly develops the symptoms associated with hyperglycemia. This article will deal with both of these types of cases.

Pathophysiology

It is important to understand the basic pathophysiology of juvenile diabetes in order to comprehend how and why its symptoms occur. Diabetes is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin. Insulin is produced by the beta cells in the islets of Langerhans within the pancreas. An absence, destruction or other loss of these cells results in type 1 diabetes, also known as insulin-dependent diabetes mellitus. Most children with diabetes have type 1 diabetes and will have a lifetime dependence on exogenous insulin.

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