Early management and assessment

Paediatric patients who presents with a hyperglycemic crisis will be managed in A&E and includes the following:

• general resuscitation
  • airway
    • ensure that the airway is patent and if the child is comatose, insert an airway
    • if consciousness reduced or child has recurrent vomiting, insert N/G tube, aspirate and leave on open drainage
  • breathing
    • give 100% oxygen by face-mask.
  • circulation
    • insert IV cannula and take blood samples for initial investigations
    • cardiac monitor for T waves (peaked in hyperkalaemia)
    • unshocked patient is started on 0.9% saline
    • if the child is in shock (poor peripheral pulses, poor capillary filling with tachycardia, and/or hypotension) give 10 ml/kg 0.9% (normal) saline as a bolus, and repeat as necessary to a maximum of 30 ml/kg.
• confirmation of the diagnosis
  • history - polydipsia, polyuria
  • clinical - acidotic respiration, dehydration, drowsiness, abdominal pain/vomiting
  • biochemical - high blood glucose on finger-prick test (>11 mmol/l), blood pH < 7.3 and /or HCO3< 15 mmol/l, finger prick blood ketones >3.0 mmol/l, glucose and ketones in urine
• initial investigations
  • blood glucose
  • urea and electrolytes (electrolytes on blood gas machine give a guide until accurate results available)
  • blood gases (venous blood gives very similar pH and pCO2 to arterial)
  • near patient blood ketones if available (superior to urine ketones)
  • other investigation if clinically indicated e.g. PCV and FBC, CXR etc (1)

Reference:

• (1) British Society of Paediatric Endocrinology and Diabetes (BSPED) 2013. Guidelines for the management of DKA in young people under the age of 18 years