Pediatric emergency medicine trisk 1870 1870
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To identify patients with hyperglycemia and/or mild ketoacidosis and initiate treatment per
algorithm.
To create a sick day plan for patients able to orally rehydrate, create sick day plan for them
upon discharge with close follow-up with their diabetes specialist.
CLINICAL PEARLS AND PITFALLS
Fasting laboratory plasma glucose of greater than 126 mg/dL or a random glucose
greater than 200 mg/dL on two separate occasions is diagnostic of diabetes in an
otherwise healthy person. This definition was developed by specialists in adult
diabetes and may not be completely applicable to the pediatric population.
Hyperglycemia in ED setting can result from numerous triggers including
intercurrent illness or trauma in patient with known DM, new-onset DM, other
illnesses associated with hyperglycemia, spurious blood sample, and medication
effect.
For purposes of definition, a patient with hyperglycemia does not have DKA if
venous pH is greater than 7.3 and serum bicarbonate is greater than 15 mEq/L.
Current Evidence
As noted in the previous section on diabetes and the following section on hypoglycemia,
glucose homeostasis reflects the balance between glucose input (from gut absorption, hepatic
glycogen breakdown, or gluconeogenesis) and disposal (via storage or oxidation). With the
exception of gut absorption, this process is largely regulated by insulin, although
counterregulatory hormones also have a significant effect. Furthermore, tissue factors and
medication also impact the insulin effect.
Clinical Considerations
Clinical Recognition
Plasma glucose concentrations in the 200 to 300 mg/dL range rarely result in symptoms. This
level of hyperglycemia may be accompanied by intermittent increased frequency of urination;
however, parents are rarely aware of their child’s frequency of urination once the child is toilet
trained unless the frequency becomes disruptive (e.g., nocturia or “accidents” at school).
Children and adolescents have no sense of what is the normal frequency of urination, so they
rarely complain unless the frequent urination is accompanied by dysuria. Higher levels of
glucose (greater than 300 mg/dL) may be associated with subtle clinical findings, such as
blurring of vision or dryness of oral membranes. Significant hyperglycemia may occur without
significant symptoms and can be tolerated for a prolonged period without clinical signs.
Triage
Generally, these patients are asymptomatic and very well appearing. Care must be taken to
distinguish from patients with more severe diabetic ketoacidosis and possible cerebral edema.
Initial Assessment/H&P
