Emergency Room Management Guidelines

for the Child with Type 1 Diabetes

Diabetic Ketoacidosis (DKA) Hypoglycemia (moderate or severe)
History (some or all of) Clinical Signs generally include History Clinical Signs
• Polyuria • Tiredness • Deep sighing respirations – (Kussmaul breathing) Recent hypoglycemic event requiring treatment by another Seizures
• Polydipsia • Vomiting with no wheeze or rhonchi person with Glucagon or oral glucose especially if AND/ Hemiparesis
• Weight loss • Confusion • Smell of ketones on breath – Increased confusion OR Any localizing neurological findings
• Abdominal pain • Difficulty breathing • Lethargy/drowsiness – Decreased consciousness Altered state of consciousness
• Dehydration – mild to severe
Obtain a blood glucose (capillary)
• Urine ketones/glucose Electrolytes and Gases not usually necessary
• Capillary glucose STAT in ER
• Venous blood – glucose, gases, electrolytes, urea, creatinine IF child is active, alert, and tolerating oral fluids well, then encourage
• Other as indicated glucose-containing drinks at least at maintenance fluid rate
OTHERWISE
Start IV – at least 5% glucose in saline at maintenance rate, regardless of blood glucose level
Confirm DKA
• Ketonuria • Serum Bicarbonate <18 mmol/L
• Glucose >11 mmol/L • Consult Pediatrician immediately If drowsy, and any neurological impairment, localized or generalized:
• pH <7.3 IV Bolus of 0.25 - 0.5 grams/kg of 50% glucose (0.5 - 1.0 ml/kg) OR 25% glucose (1 - 2 ml/kg)

Hypotension (PALS Values) Continue IV glucose until:

Age Systolic BP (mm/Hg)
Vascular Decompensation No Vascular 1. Child has no further neurological signs and
<1 month < or = 60
(with or without coma) Decompensation 2. Child is no longer drowsy, confused, irrational or restless.
1 month to 1 year < or = 70 • Hypotension (see box)
(May take up to 12 hours if hypoglycemic encephalopathy is present)
1 to 10 years < or = 70 + (2 x age in years) • Decreased level of consciousness
>10 years < or = 90 3. Maintain blood glucose >8 mmol/L as above until IV fluids discontinued
4. Then, change to oral sugar-containing fluids

Resuscitation • Clinically Dehydrated • Minimally dehydrated Discharge

• Assess airway and breathing • Hyperventilating • Tolerating fluids orally Discharge ONLY when child is
• Apply 100% oxygen by mask OR • Normal bowel sounds • Fully alert
• Normal Saline 10 ml/kg to • Vomiting • Normal mental status • Tolerating oral fluids and
expand vascular space • Normal BP • Free of neurological signs.
THEN (lying and sitting)
• Decrease to 5 - 7 ml/kg/hr with
Potassium Chloride as noted below Observation and Monitoring
Normal Saline • Oral hydration • Determine cause and arrange for follow-up
• Only infuse Sodium Bicarbonate
7 ml/kg over 1st hour • S/C insulin • Decrease all insulin doses by 20% for next 24 hrs
(1 - 2 mEq/kg over 1 hour) if:
with Potassium Chloride (see illness rules) • Renew prescription for Glucagon if used
1. Life-threatening hyperkalemia
as noted below
2. Inotrope-resistant shock
THEN 3.5 - 5 ml/kg/hr
3. Cardiac Arrest
Intercurrent Illness
After 1st Hour of IV Fluids
• If history of voiding within last hour and Potassium <5.5 mmol/L, add 40 mEq/L of Potassium Chloride to IV fluid If emesis 2x in past 4 hours, No emesis BUT No emesis
• Aim to keep Potassium between 4 - 5 mEq/L keep NPO for 4 - 6 hours Not drinking Tolerating fluids
• Continuous insulin infusion 0.1 units/kg/hr = 1ml/kg/hr (of solution of 25 units of
Regular Insulin in 250 ml Normal Saline). Include this amount in total fluid intake.
• Capillary glucose • Capillary glucose
• DO NOT GIVE BOLUS OF INSULIN
• Venous blood – glucose, gases, electrolytes, urea • Venous blood – glucose, gases,
• Continuous cardio-respiratory monitoring (with EKG tracing)
• Urine ketones urea, electrolytes
• Urine ketones
Neurological deterioration Acidosis not Acidosis improving
Headache, irritability, improving • Blood glucose <15 mmol/L IV fluids
decreased level of consciousness, (in 3 - 4 hours) OR • Severely dehydrated –
decreased HR • Check insulin • Blood glucose falls >5 mmol/L/h Normal Saline (10 ml/kg) over 1 hour Maintenance IV fluids
delivery system after 1st hour of fluids • If glucose >20 mmol/L then • 4 ml/kg/hr for 1st 10 kg
First rapidly exclude hypoglycemia Normal Saline at maintenance volumes • 2 ml/kg/hr for next 10 kg
by capillary blood glucose • Consider sepsis • Change IV to D5/Normal Saline
• Contact Tertiary with Potassium as above • If glucose <20 mmol/L then D5W./ • 1 ml/kg/hr for next 10 kg
measurement Normal Saline at maintenance volumes
THEN Pediatric • Decrease insulin to 0.04 - 0.05 U/kg/hr =
Diabetes Centre 0.4 - 0.5 ml/kg/hr of standard solution as above • Once voiding, add Potassium Chloride
Treat for cerebral edema
• Blood glucose <10mmol/L change to
D10/Normal Saline with Potassium as above
Hyperglycemic Hypoglycemic
• 20% Mannitol 5 ml/kg over 20 minutes • Improvement • Do not omit insulin • Do not omit insulin
• If Sodium has declined, administer • Clinically well • Use S/C insulin unless acidotic (see DKA guidelines) • Decrease next scheduled insulin dose by 10 - 20%
2 - 4 ml/kg of 3% saline over 10 - 20 min. • Tolerating oral fluids • If Blood Glucose >11 mmol/L and mod-large • If not tolerating oral fluids then follow IV
THEN • Ph >7.3 ketones, then give usual insulin PLUS extra short as per hypoglycemia guidelines
Normal Saline @ maintenance IV rate • Bicarbonate >18mmol/L or rapid-acting Q4h [10 - 20% of TOTAL (N&R or H) • Otherwise encourage carbohydrate-containing fluids
• Decrease insulin to 0.04 - 0.05 U/kg/hr = daily dose]
• Start S/C insulin
0.4 - 0.5 ml/kg/hr of standard solution as above • Stop IV insulin ½ hour after S/C dose of rapid-acting
Catalogue No. 013308 450 April/09 © 2009 Queen’s Printer for Ontario

• Contact Tertiary Pediatric Diabetes Centre or 1 hour after S/C dose of regular insulin Discharge
• Admit to ICU • Determine cause of DKA • Tolerating oral fluids
• Contact regional Pediatric Diabetes Education Centre • No other reason for hospitalization
• Replace usual meal plan with carbohydrate-containing fluids

Observation and Monitoring

• Hourly blood glucose (capillary) Observation and Monitoring
• Aim for a decrease in blood glucose of 5 mmol/L/h • Input & Output Q4h
• Strict hourly documentation of fluids input/output • Blood glucose Q2-4h (keep within 4 -10 mmol/L)
• Calculate and review fluids balance at least every 4 hours • Test urine for ketones
• Hourly, at least, assessment of neurological status for a minimum of 24 hours
• 2 - 4 hours after start of IV – electrolytes, venous gases – then Q2-4h
• Follow Effective Osmolality = (2x measured Sodium + measured blood glucose)
• Avoid a decrease of >2 - 3 mmol/L/hr in effective osmolality by increasing IV sodium concentration