A Primer on Pediatric Diabetic Emergencies
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.
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.
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.
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.
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.
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.
The goal of prehospital treatment is to protect and maintain the airway and treat shock, if present. Every child with this diagnosis should receive supplemental oxygen and have an IV with normal saline started. Administer a bolus of saline (20 ml/kg body weight). A second or third bolus may be necessary, especially where transport times are lengthy. As always, determine the blood sugar, and recheck it if transit times are prolonged. Since nausea and vomiting frequently occur, be prepared to utilize standard maneuvers to prevent aspiration of stomach contents.
The mainstay of treatment is intravenous insulin, usually administered as a continuous infusion. It is a rare region of the country where this is an approved protocol for the prehospital provider. Since in most cases this is not an option, rapid transfer to an appropriate facility is the order of the day.
Considerations for Kids
The first question to prehospital evaluation and management of pediatric diabetic emergencies is how the provider determines the patient’s blood glucose level. The treatment of hyperglycemia is different than the treatment of hypoglycemia, so knowing the blood glucose level is crucial to deciding on the correct approach.
In the early days of EMS, the only method available was to use a product called Dextrostix. These were strips of celluloid whose ends were coated with a chemical that would change color based on the amount of glucose in a drop of blood applied. Users had to wait a specific number of seconds and then match the color on the strip to a color chart provided. This gave a range, rather than a specific number. Obviously, there were many problems with this method that could lead to inaccuracies. Yet some jurisdictions may still utilize these strips in the field.
Today glucometers are widely available. Diabetic patients routinely use them to quickly and accurately measure and record their blood glucose levels during activities or at home. Glucometers are outstanding tools for use in the prehospital environment, and in many regions of the country are standard on ambulances.
Another subject to consider is who should utilize glucometers in the field. In some places they are restricted to ALS providers only, while in others BLS providers are trained to use them. It seems logical that if a 10-year-old diabetic patient can be taught to correctly use a glucometer, an appropriately trained EMT can utilize it also. Certainly that would be helpful in diagnosing diabetic-related medical problems.
A further consideration is cost. Glucometers have become relatively inexpensive and need very little maintenance. It is necessary to buy the test strips, however. In many areas businesses will be happy to donate a glucometer to the local ambulance corps—in particular pharmacies, since they profit from the sale of test strips.
It seems prudent for all regions to place glucometers on their ambulances and develop protocols for their use. It would also be beneficial to consider allowing use by both BLS and ALS providers with appropriate training.
Another issue to consider is when to divert the patient to a specialty pediatric center for evaluation and treatment. If the pediatric center is reasonably close, such diversion makes great sense. However, when the transit time to such a facility is prolonged, the patient will probably benefit from more immediate care in a general hospital emergency department. If needed, the general hospital can arrange for transfer to more definitive care after the child has been stabilized.
Caring for pediatric emergency conditions is always stressful for the prehospital provider. The fact that diabetic conditions are fairly common does not reduce this stress level. The key to providing appropriate evaluation and management of the child with a diabetic emergency is to become familiar with the possible presentations you’re likely to encounter. These presenting symptoms may be variable, potentially leading to incorrect diagnoses. Such familiarity will decrease stress and allow the provider to deliver optimum care.
Bernard Beckerman, MD, is an associate professor in the Physician Assistant Program at York College-City University of New York, deputy chief for medical affairs for the Plainview Fire Department and a longtime member of EMS World's editorial advisory board.?
John Graffeo, MS, RPA-C, is an associate professor and clinical coordinator at York College (CUNY) in Jamaica, NY.