Pediatric emergency medicine trisk 1877 1877
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plasma glucose should then be maintained by an infusion of dextrose at a rate of 6 to 8
mg/kg/min. Generally, this goal can be accomplished by providing 10% dextrose at one and
one-half times the maintenance rate. While waiting for vascular access, mucosal and enteral
routes should be considered if can be done safely. Glucagon (0.03 mg/kg up to a maximum of
1 mg intramuscularly) may be used to treat hypoglycemia that is known to be caused by
hyperinsulinism but is not indicated as part of the routine therapy of hypoglycemia with an
unknown etiology. Glucocorticoids should not be used because they have minimal acute
benefit and may delay identification of the cause of hypoglycemia.
The adequacy of therapy should be evaluated both chemically and clinically. The plasma
glucose should be monitored frequently and consistently until a stable level higher than 70
mg/dL is attained on more than one measurement. Adrenergic symptoms should resolve
quickly. The resolution of CNS symptoms may be prolonged, particularly if the child was
initially seizing or unconscious. Seizures that do not respond to correction of hypoglycemia
should be managed with appropriate anticonvulsants (see Chapters 72 Seizures and 97
Neurologic Emergencies ). The mild acidosis (pH 7.25 to 7.35) usually seen in hypoglycemia
will correct without specific intervention. Marked acidosis (pH <7.10) suggests shock or
serious underlying disease and should be managed appropriately (see Chapter 10 Shock ).
Clinical Indications for Discharge or Admission
Any child with documented hypoglycemia not secondary to insulin therapy, or due to another
known entity, should be considered for hospitalization for careful monitoring and diagnostic
testing. Exceptions to hospitalization might include children with significant dehydration in
the setting of a gastroenteritis illness where symptoms are improving or controlled after proper
rehydration in the ED. If being considered for discharge, these children will need repeat blood
glucose measurements off IV infusions for several hours prior to discharge.
HYPOPITUITARISM
Goal of Treatment
The goal of treatment in those with known hypopituitarism includes the replacement of
essential hormones especially during times of stress such as illness or injury.
CLINICAL PEARLS AND PITFALLS
The acute presentation of hypopituitarism is most likely to occur when the child is
stressed by injury, illness, or fasting.
Children with midline neurologic defects are at risk for hypopituitarism.
Children with hypopituitarism are prone to hypoglycemia.
Hypopituitarism is associated with intracranial lesions.
Cortisol replacement in patients with adrenal insufficiency under stress conditions
is imperative.
Current Evidence
