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Emergencies
Diabetic ketoacidosis in children and
adolescents
Hypoglycaemia
Neonatal hypoglycaemia
Hypocalcaemia
Hyperthyroid crisis
Acute adrenal insufficiency – adrenal crisis
Hyponatraemia
Diabetic ketoacidosis (DKA) and
hypoglycaemia in children and adolescents
with diabetes
https://www.ispad.org/
ISPAD Clinical Practice Consensus Guidelines 2009
Chapter 10, chapter 11
There is wide geographic variation in the
frecuency of DKA at onset of diabetes, and
correlated with regional incidence of T1DM
Frequency range from 15 % to 70% in Europe
and North America
Causes:
Diabetic ketoacidosis results from absolute or
relative deficiency of circulating insulin and
the combined effects of increased levels of
counterregulatory hormones
Dehydratation
Rapid, deep (Kussmaul) respiration
Nausea, vomiting, and abdominal pain mimicing an
acute abdomen
Progressive obtundation and loss of consciousness
Increased leucocyte count with left shift
Non specific elevation of serum amylase
Fever only when infection is present
Biochemical criteria for diagnosis of DKA:
ISPAD 2009
Correct dehydratation
Correct acidosis and reverse ketosis
Restore blood glucose to near normal
Avoid complications of therapy
Identify and treat any precipitating event
Inadequate rehydration
Hypoglycaemia
Hypokalemia
Hyperchloremic acidosis
Cerebral edema
Cerebral edema ussually develops 4-12 hours
after treatment has started
Bikarbonate:
◦ Bicarbonate is not reccomended
◦ If bicarbonate is necessary (pH<6,9), cautiously give
1-2mmol/kg over 60 min in IUC.
ISPAD 2009
Hypoglycaemia: blood glucose < 3,9 mmol/l
Treatment:
◦ 5-15g glucose or sugar
◦ 100ml sweet drink (juice, sweet, tea)
Urgent treatment:
◦ Glucagon i/m, s/c
◦ 0,5 mg, for age < 12 m
◦ 1,0 mg, for age > 12 m
◦ Dextrose i/v
◦ Dextrose 10-30% at a dose 200 – 500 mg/kg, (dextrose 10% is
100mg/ml )
Often transitory
o Macroglossia;
o Macrossomia.
It is a large clinical
heterogeneity
o Macrosomia - height
and weight > 97‰
o Hemihyperplasia -
asymmetric growth of
one or more body
areas, organs.
o Macroglossia.
o Neonatal
hypoglycaemia.
o Hernia umbilicalis, diastasis m. recti.
o Visceromegalia
o Germinal tumors of childhood
o (Wilms tumor, hepatoblastoma,
neuroblastoma, rabdomiosarcoma).
o Renal dysplasia, nephromegalia,
nephrocalcinozė.
o Cardiomegalia, congenital heart
disease, cardiomiopatia.
In asymptomic newborns in the risk group
glycemia should be measured in the
capillary blood:
2,4,6,8,10,12,18,24,36,48 and 72 hours
after birth
Normal weight full-term infants:
Normal:
Ca <2 mmol/l or Ca++ <1,2 mmol/l
Early neonatal hypocalcaemia:
First 3-4day after birth
Symptomatic :
Hypomagnesaemia
Alkalosis
Next steps:
Ca infusion 1-2 mmol/kg/day via central line
Age group:
Mostly neonatal, but rare
Infection
Trauma
Surgical intervention;
Sympathomimetic use;
Anti-thyroid drug treatment interruption;
Radioactive iodine therapy.
Irritabily
Restlessness
Voracious feeding
Weight loss or failure to gain weight
Temperature >38,5 C°
Tachycardia (inadequate C°)
Sings of cardiac failure
Tachypnoe
Gastrointestinal disorder (vomiting,
diarrhea)
Goitre
Coma
fT3
fT4
TSH
Thyroid receptor antibody titre
Monitoring of respiratory and cardiovascular
function
o Genetics
o Mutation ALD gene, Xq28chromosome
o ALD protein may be to transport VLCFA-COA synthetase
Classification :
1. Hypovolaemic hyponatraemia
2. Euvolaemic hyponatraemia
3. Hypervolaemic hyponatraemia
Renal loss:
Adrenal insufficiency (MCC deficiency)
Cerebral salt wasting syndrome
Tubular defect
Extra renal losses:
Gastrointestinal tract (vomiting, diarrhea,
pancreatitis, intestinal fistula)
Skin (burns)
Lungs
Syndrome of inappropriate secretion of
antidiuretic hormone (SIADH)
ACTH – deficiency (glucocorticoid)
Psychogenic polydipsia
Hypothyroidism
Water intoxication
Nephrotic syndrome
Cirrhosis
Heart failure
Renal failure