Overview
Diabetic Emergencies in Children
Quick Reference
Critical Alerts
- Cerebral edema is the major DKA complication in children: Monitor closely
- Fluid resuscitation: Slower than adults: 10-20 mL/kg bolus, then gradual
- Insulin infusion: 0.05-0.1 units/kg/hr: Do NOT bolus
- Potassium replacement: Start early: Once K <5.5 and urine output confirmed
- Hypoglycemia can kill quickly: Treat immediately with glucose
- New-onset DKA: Consider type 1 diabetes debut
Key Diagnostics (DKA)
| Parameter | Value |
|---|---|
| Blood glucose | >00 mg/dL (11 mmol/L) |
| Venous pH | <7.3 |
| Serum bicarbonate | <15 mEq/L |
| Ketones | Positive (blood β-hydroxybutyrate > mmol/L) |
DKA Severity
| Severity | pH | Bicarbonate |
|---|---|---|
| Mild | 7.25-7.30 | 15-18 mEq/L |
| Moderate | 7.10-7.24 | 10-14 mEq/L |
| Severe | <7.10 | <10 mEq/L |
Emergency Treatments
| Condition | Treatment | Details |
|---|---|---|
| DKA (initial) | NS 10-20 mL/kg over 1-2 hours | Do not exceed 40 mL/kg in first 4 hours |
| DKA (insulin) | 0.05-0.1 units/kg/hr IV infusion | Start after initial fluid bolus |
| Hypoglycemia | Dextrose 0.5-1 g/kg IV | D10W or D25W |
| Cerebral edema | Mannitol 0.5-1 g/kg or 3% saline 2.5-5 mL/kg | Emergent |
Definition
Overview
Diabetic emergencies in children primarily include diabetic ketoacidosis (DKA) and hypoglycemia. DKA is the most common cause of death in children with type 1 diabetes, primarily due to cerebral edema. Early recognition and careful management are essential. Hypoglycemia can occur in diabetic children on insulin and requires immediate treatment.
Classification
Diabetic Ketoacidosis (DKA):
| Criterion | Value |
|---|---|
| Hyperglycemia | >00 mg/dL (11 mmol/L) |
| Acidosis | Venous pH <7.3 or bicarbonate <15 mEq/L |
| Ketosis | Blood ketones > mmol/L or urine ketones moderate/large |
Hypoglycemia:
| Severity | Blood Glucose |
|---|---|
| Mild | 54-70 mg/dL (3-3.9 mmol/L) |
| Moderate | 40-54 mg/dL (2.2-3 mmol/L) |
| Severe | <40 mg/dL (2.2 mmol/L) or symptomatic requiring assistance |
Epidemiology
- DKA at diagnosis: 20-40% of children with new-onset T1DM present in DKA
- DKA in known diabetics: 1-10% per year
- Cerebral edema incidence: 0.5-1% of pediatric DKA
- Cerebral edema mortality: 21-24%
- Hypoglycemia: Common in insulin-treated diabetes
Etiology
DKA Precipitants:
| Cause | Notes |
|---|---|
| New-onset T1DM | Most common cause in children |
| Missed insulin doses | Adolescents, noncompliance |
| Insulin pump failure | Rapid DKA onset |
| Infection/illness | Increased insulin requirements |
| Trauma, surgery | Stress hyperglycemia |
Hypoglycemia Causes:
| Cause | Notes |
|---|---|
| Insulin excess | Dosing error, missed meal |
| Exercise | Increased glucose utilization |
| Sulfonylurea use (rare in peds) | Prolonged hypoglycemia |
| Alcohol (adolescents) | Inhibits gluconeogenesis |
Pathophysiology
DKA Mechanism
- Insulin deficiency + counter-regulatory hormone excess:
- Glucagon, cortisol, catecholamines, GH increase
- Hyperglycemia:
- Decreased glucose uptake, increased gluconeogenesis
- Osmotic diuresis → Dehydration
- Ketogenesis:
- Lipolysis → Free fatty acids → Ketone bodies (β-hydroxybutyrate, acetoacetate)
- Anion gap metabolic acidosis
- Electrolyte derangements:
- Total body potassium depletion (despite normal/high serum K)
- Phosphate depletion
- Sodium losses
Cerebral Edema in Pediatric DKA
Risk Factors:
- Younger age (<5 years)
- New-onset diabetes
- Severe DKA (low pH, low bicarb)
- Elevated BUN at presentation
- Rapid fluid administration (controversial)
- Failure of Na to rise with treatment
- Bicarbonate administration (controversial)
Mechanism:
- Not fully understood
- May involve osmotic shifts, vasogenic edema, cellular injury
Hypoglycemia Mechanism
- Insulin excess → Excessive glucose uptake
- Symptoms from neuroglycopenia (brain glucose deprivation)
- Counter-regulatory response (catecholamines) causes autonomic symptoms
Clinical Presentation
DKA Symptoms
| Category | Symptoms |
|---|---|
| Hyperglycemia | Polyuria, polydipsia, weight loss |
| Dehydration | Dry mouth, decreased urine output, tachycardia |
| Acidosis | Kussmaul respirations (deep, rapid), fruity breath |
| GI | Nausea, vomiting, abdominal pain |
| Neurologic | Lethargy, confusion (concerning for cerebral edema) |
Hypoglycemia Symptoms
| Category | Symptoms |
|---|---|
| Autonomic | Sweating, tremor, palpitations, hunger, pallor, anxiety |
| Neuroglycopenic | Confusion, irritability, drowsiness, slurred speech, seizures, coma |
History
DKA Key Questions:
Hypoglycemia Key Questions:
Physical Examination
DKA:
| Finding | Significance |
|---|---|
| Dehydration | Tachycardia, dry mucous membranes, decreased skin turgor |
| Kussmaul respirations | Acidosis compensation |
| Fruity/acetone breath | Ketosis |
| Abdominal tenderness | DKA-associated, rule out surgical abdomen |
| Altered mental status | Severe DKA, impending cerebral edema |
Hypoglycemia:
| Finding | Significance |
|---|---|
| Diaphoresis | Autonomic response |
| Tremor, tachycardia | Catecholamine surge |
| Altered LOC, confusion | Neuroglycopenia |
| Seizure | Severe hypoglycemia |
Known diabetic? Insulin type, pump?
Common presentation.
Recent illness or infection?
Common presentation.
Missed insulin doses?
Common presentation.
Timeline of polyuria, polydipsia, weight loss
Common presentation.
Nausea, vomiting, abdominal pain
Common presentation.
Altered mental status
Common presentation.
Red Flags
Cerebral Edema Warning Signs (DKA)
| Finding | Action |
|---|---|
| Headache, altered mental status | Consider cerebral edema |
| Bradycardia, hypertension (Cushing response) | Emergent treatment |
| Pupillary changes | Herniation imminent |
| Posturing | Herniation |
| Rising serum sodium that fails to rise with treatment | Risk factor |
| Rapid neurological deterioration | Treat immediately |
Treat empirically for cerebral edema if suspected—do NOT wait for imaging
DKA Red Flags
| Finding | Concern |
|---|---|
| pH <7.1 | Severe DKA |
| Altered consciousness | Cerebral edema or severe acidosis |
| Shock (hypotension, poor perfusion) | Requires aggressive resuscitation |
| Age <2 years | Higher risk of cerebral edema |
| New-onset diabetes | Higher risk of cerebral edema |
Differential Diagnosis
DKA-Like Presentations
| Diagnosis | Features |
|---|---|
| Hyperosmolar hyperglycemic state (HHS) | Very high glucose (>00), minimal ketosis, altered LOC |
| Salicylate poisoning | Anion gap acidosis, tinnitus, history |
| Sepsis | Fever, source of infection |
| Gastroenteritis | Vomiting, diarrhea, less acidosis |
| Inborn errors of metabolism | Younger age, recurrent acidosis |
| Starvation ketosis | Mild ketosis, no hyperglycemia |
Hypoglycemia Differential
| Diagnosis | Features |
|---|---|
| Insulin overdose | Known diabetic, insulin use |
| Insulinoma | Recurrent fasting hypoglycemia, non-diabetic |
| Adrenal insufficiency | Hypotension, electrolyte abnormalities |
| Sepsis | Hypoglycemia in severely ill |
| Ingestion (sulfonylurea) | History of access |
Diagnostic Approach
Initial Labs (DKA)
| Test | Purpose |
|---|---|
| Blood glucose | Hyperglycemia confirmation |
| Venous blood gas | pH, pCO2 |
| BMP | Electrolytes, BUN, creatinine, anion gap |
| Serum ketones (β-hydroxybutyrate) | Ketosis confirmation |
| Urinalysis | Glucose, ketones |
| CBC | Leukocytosis common (even without infection) |
| HbA1c | Chronic glycemic control |
Anion Gap Calculation
- Anion gap = Na – (Cl + HCO3)
- Normal: 8-12 mEq/L
- Elevated in DKA due to ketoacids
Corrected Sodium
- Corrected Na = Measured Na + 1.6 × [(glucose - 100) / 100]
- Important for assessing true dehydration and cerebral edema risk
Monitoring
| Parameter | Frequency |
|---|---|
| Blood glucose | Hourly |
| Electrolytes, VBG | Every 2-4 hours |
| Neurological status | Every hour initially |
| Fluid input/output | Continuous |
Treatment
DKA Management Principles
- Fluid resuscitation: Restore intravascular volume, avoid rapid correction
- Insulin infusion: Inhibit ketogenesis, lower glucose
- Electrolyte replacement: Especially potassium
- Monitor for cerebral edema: Most important complication
- Identify/treat precipitant: Infection, missed insulin
Phase 1: Initial Resuscitation (First 1-2 Hours)
Fluid Bolus:
| What | How |
|---|---|
| NS (0.9% saline) | 10-20 mL/kg over 1-2 hours |
| Repeat if needed | Up to 40 mL/kg in first 4 hours |
| Goal | Restore perfusion, NOT rapid rehydration |
Do NOT give insulin bolus: Start infusion after initial fluid
Phase 2: Rehydration and Insulin
Maintenance Fluids:
- Calculate deficit + maintenance over 24-48 hours
- Use NS initially, then 0.45-0.9% saline with potassium
- Avoid >1.5-2× maintenance rate
Insulin Infusion:
| Dose | Notes |
|---|---|
| 0.05-0.1 units/kg/hr | Start 1-2 hours after fluids |
| Do NOT bolus | Increases cerebral edema risk |
| Goal glucose drop | 50-100 mg/dL/hr |
Add Dextrose When Glucose <300 mg/dL:
- Switch to D5 0.45% NS or D10 0.45% NS
- Continue insulin to clear ketones (NOT just normalize glucose)
Potassium Replacement
| Serum K | Action |
|---|---|
| >.5 mEq/L | Hold potassium until K <5.5 |
| 4-5.5 mEq/L | Add 20-40 mEq/L to fluids |
| 3.5-4 mEq/L | Add 40-60 mEq/L to fluids |
| <3.5 mEq/L | Hold insulin until K repleted; higher replacement |
Beware: Serum K falls rapidly with insulin—replace early
Bicarbonate: NOT Routinely Recommended
- No proven benefit in pediatric DKA
- May increase cerebral edema risk
- Consider ONLY if pH <6.9 with hemodynamic compromise
Cerebral Edema Treatment
Signs: Headache, altered LOC, bradycardia, hypertension, posturing
Treatment:
| Agent | Dose |
|---|---|
| Mannitol | 0.5-1 g/kg IV over 20 minutes |
| OR Hypertonic saline (3%) | 2.5-5 mL/kg IV over 10-15 minutes |
- Elevate head of bed to 30°
- Reduce IV fluid rate by 1/3
- Intubation if needed (avoid hyperventilation)
- Urgent neurosurgery consult
- CT head (but do NOT delay treatment)
Hypoglycemia Treatment
Mild (Able to Swallow):
- 15-20 g fast-acting carbohydrate (juice, glucose tabs)
- Recheck glucose in 15 minutes
Severe (Unable to Swallow/LOC Impaired):
| Route | Treatment |
|---|---|
| IV Dextrose | 0.5-1 g/kg (D10W: 5-10 mL/kg; D25W: 2-4 mL/kg) |
| IM Glucagon (if no IV) | 0.5 mg (<25 kg) or 1 mg (>5 kg) |
Follow with complex carbs: Once awake, give snack to prevent recurrence
Disposition
ICU Admission (DKA)
- Severe DKA (pH <7.1, HCO3 <5)
- Altered mental status
- Cerebral edema or high risk
- Hemodynamic instability
- Age <2 years
- New-onset diabetes
Floor Admission (DKA)
- Mild-moderate DKA, stable
- Responding to treatment
- No cerebral edema signs
Discharge (Hypoglycemia)
- Resolves with treatment
- Cause identified and corrected
- Diabetes education provided
- Safe to go home with supervision
Follow-Up
| Situation | Follow-Up |
|---|---|
| DKA resolved | Endocrinology within 1 week; diabetes education |
| New-onset diabetes | Inpatient diabetes education before discharge |
| Recurrent hypoglycemia | Endocrinology; adjust insulin regimen |
Patient Education
DKA Prevention (For Families)
- Never stop insulin, even when sick
- Check blood glucose and ketones when ill
- Sick day rules: Extra fluids, adjust insulin, seek care early
- Recognize DKA warning signs: Vomiting, abdominal pain, rapid breathing
Hypoglycemia Prevention
- Eat regular meals and snacks
- Carry fast-acting glucose at all times
- Recognize early symptoms (hunger, shakiness)
- Treat immediately—don't wait
When to Seek Emergency Care
- Persistent vomiting, unable to keep fluids down
- Moderate-large ketones
- Altered mental status, confusion
- Rapid breathing
- Blood glucose very high or very low not responding to treatment
Special Populations
Infants and Toddlers (<5 Years)
- Higher risk of cerebral edema
- Symptoms may be non-specific
- More cautious fluid management
Adolescents
- Insulin omission (intentional) common
- Eating disorders (diabulimia)
- Psychosocial support essential
Insulin Pump Users
- DKA can develop rapidly (no long-acting depot)
- Remove pump; start IV insulin
- Evaluate for pump malfunction
New-Onset Diabetes
- Higher risk of severe DKA and cerebral edema
- Requires comprehensive diabetes education before discharge
- Endocrinology referral essential
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Hourly neuro checks during DKA | 100% | Cerebral edema detection |
| Insulin infusion started within 2 hours | >5% | After initial fluids |
| Potassium monitored every 2-4 hours | 100% | Prevent hypokalemia |
| Avoid bicarbonate unless pH <6.9 | >5% | Reduces complications |
| Diabetes education before discharge | 100% | Prevent recurrence |
Documentation Requirements
- DKA severity (mild/moderate/severe)
- Fluid rates and composition
- Insulin infusion rate
- Hourly glucose and neuro checks
- Potassium levels and replacement
- Cerebral edema assessment
Key Clinical Pearls
DKA Pearls
- Cerebral edema is the killer: Monitor neuro status religiously
- Slow fluid resuscitation: Avoid rapid correction
- Insulin infusion, NO bolus: Reduces cerebral edema risk
- Potassium drops fast: Replace early once K <5.5
- Don't stop insulin when glucose normalizes: Continue until ketones clear
- Bicarbonate is rarely indicated: May worsen outcomes
Hypoglycemia Pearls
- Treat immediately: Brain damage occurs quickly
- D10W safer than D50W in children: Less hyperglycemia; less extravasation injury
- Glucagon for no IV access: Effective IM/SC
- Find the cause: Missed meal, excess insulin, exercise
- Follow with complex carbs: Prevent recurrence
Disposition Pearls
- Low threshold for ICU in pediatric DKA: Especially severe or young
- New-onset diabetes = education before discharge: Essential
- Endocrine follow-up for all: Optimize long-term management
References
- Wolfsdorf JI, et al. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes. 2018;19(Suppl 27):155-177.
- Glaser N, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med. 2001;344(4):264-269.
- Kuppermann N, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis (PECARN FLUID Trial). N Engl J Med. 2018;378(24):2275-2287.
- American Diabetes Association. Standards of Medical Care in Diabetes—2024. Diabetes Care. 2024;47(Suppl 1).
- Rewers A, et al. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: SEARCH for Diabetes in Youth. Pediatrics. 2008;121(5):e1258-e1266.
- Koves IH, et al. The accuracy of clinical assessment of dehydration during diabetic ketoacidosis in childhood. Diabetes Care. 2004;27(10):2485-2487.
- Edge JA, et al. The risk and outcome of cerebral oedema developing during diabetic ketoacidosis. Arch Dis Child. 2001;85(1):16-22.
- UpToDate. Diabetic ketoacidosis in children: Treatment. 2024.