Pediatric emergency medicine trisk 1871 1871
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In the ED, hyperglycemia is likely to be seen in several different situations. First, the child
may be known to have diabetes and present with an intercurrent illness or traumatic injury.
Both illness and injury result in increased counterregulatory hormones, which may lead to
relative insulin resistance and hyperglycemia. The second presentation is the child for whom
diabetes is suspected because of classical symptoms of polyuria, polydipsia, and polyphagia
accompanied by weight loss. Almost half of children with new-onset diabetes mellitus present
to their pediatrician or to the ED in this way. Third, some medical conditions are associated
with persistent hyperglycemia, such as recurrent urinary tract infections and vaginal yeast
infections. Furthermore, type 2 diabetes is increasingly being reported in minority adolescents;
in many, hyperpigmentation of the posterior neck and axilla (acanthosis nigricans) may be
noted. Fourth, a laboratory panel obtained for some other reason (e.g., abdominal pain) may
reveal hyperglycemia.
If a child is severely ill and has concomitant hyperglycemia, close attention should be paid
to the underlying illness. Severity of hyperglycemia in the setting of critical illness is
correlated with mortality, and it can be thought of as a general index of illness severity in this
nondiabetes setting.
Management/Diagnostic Testing
Children who are mildly dehydrated (5%) with slight acidosis will benefit from an IV fluid
bolus (10 to 20 mL/kg of isotonic crystalloid); furthermore, this bolus may be given while
awaiting laboratory test results.
Insulin therapy can be initiated subcutaneously, at a total daily dose of 0.25 to 0.5
Unit/kg/day for the prepubertal child and 0.5 to 0.75 Unit/kg/day for the adolescent. Using the
basal-bolus approach, one-half of the total daily dose is administered as insulin glargine or
detemir, two 24-hour–acting analogs, and rapid-acting insulin (lispro, aspart) is dosed as a
combination of coverage for ingested carbohydrates and as a correction for the degree of
hyperglycemia above a chosen target—these initial dosages should be calculated along with
the help of a consulting diabetes specialist.
Hyperglycemia associated with critical illness, in a patient without diabetes, should be
managed in the context of the underlying illness. Specific therapy for hyperglycemia should
generally not be initiated in the ED, but can generally wait until the patient arrives in the ICU.
Clinical Indications for Discharge or Admission
Some children with new-onset diabetes may also have hyperglycemia without ketoacidosis or
with only mild acidosis. Generally, these patients are engaged in a 1- to 2-day program of
intensive diabetes education to teach the family and stabilize the insulin dosage; these
educational programs require multidisciplinary input from professional diabetes educators,
nutritionists, and social workers, and can take place in the inpatient or outpatient setting.
Children with known diabetes often develop hyperglycemia and ketosis without significant
acidosis (venous pH greater than 7.3 or bicarbonate greater than 15 mEq/L) during the course
of intercurrent illness, especially gastroenteritis, or secondary to omission of insulin doses.
Once the laboratory results are available, the physician must decide whether to hospitalize the
child, continue treatment in the ED, or send the child home. Several factors must be
considered before sending a child home.
