When Sugar Turns Sour: A Look at Pediatric DKA
"MS 154 respond to a child unconscious, non-responsive, unknown cause."
You arrive at the address and are met by the patient's mother. She tells you that her daughter is in bed and can't be awaken, as she's been sick for a few days. As you assess the scene and find it safe to continue your response, you are led to a bedroom where you hear moaning. From the doorway, you begin utilizing the Pediatric Assessment Triangle (PAT). General appearance is poor as the young girl is not responding to her father's voice. She is moaning and her lips appear dry. You continue towards her, introduce yourself, and notice her breathing is accelerated.
Two major "red flags" from the PAT exist; your initial thoughts have confirmed that this child is probably significantly sick and in need of a quick, yet safe transport to definitive care. Now at the patient's side, you feel her skin and find it cool to the touch, showing signs of dehydration, and mottled about the abdomen and thighs. Her capillary refill is slowed to four seconds distally, which is consistent with the weak distal pulses felt.
As you gather formal vital signs, the parents tell you that Kathy, an otherwise healthy nine-year-old girl, has had flu-like symptoms, nausea, and vomiting for about four days and they are worried that she's contracted the swine flu. Her vital signs are: Pulse = 142 beats per minute and weak distally, Respirations = 34 breaths per minute, BP = 88/40, Pulse Ox = 98 percent on room air. Because of her "cool to the touch" status, a tympanic temperature is taken and recorded to be 92.50 F (33.50 C). Her capillary refill is greater than three seconds and she is only responding to painful stimuli.
Deciphering the clues
Kathy's presentation is one that Sherlock Holmes may enjoy as she is obviously sick, yet the etiology could be from a number of different causes. What we know right now is that Kathy is "SICK" and needs to be transported "QUICK," but what is actually causing her to be in this state of crisis? What is wrong with Kathy? Is she in threat of dying from the swine flu?
In conjunction with the American obesity epidemic, pediatric diabetic ketoacidosis (DKA) is on the rise. DKA is defined as "a state of absolute or relative insulin deficiency resulting in hyperglycemia and an accumulation of ketoacids in the blood with subsequent metabolic acidosis" (pH<7.30; serum bicarbonate < 15 mmol/L). The severity of DKA is defined by venous pH. As such, a pH greater than 7.2 is considered mild, a pH between 7.1 and 7.2 is considered moderate, and a pH less than 7.1 is severe. DKA is thus a state of relative or absolute insulin deficiency combined with a failure of the counter regulatory hormones to respond adequately. The body is tricked into thinking it needs to produce more glucose, thereby worsening the severity.
The cascade of metabolic events includes the induction of a hyperosmolar state or the excretion of fluids, leading to hypovolemia and electrolyte imbalances. This creates inadequate tissue perfusion or shock, which in turns leads to lactic acidosis and a further lowering of their pH. The body's response continues to be counterproductive by burning alternative fuel sources, producing ketones. The body responds to the excess ketone production by increasing the respiratory rate, but this buffering effect is frequently inadequate to correct or compensate for the magnitude of the elevated glucose. As ketone levels increase, they spill into the urine and result in metabolic acidosis without therapeutic intervention. Once the cascade of deterioration has begun, the child must be cared for as if they are in a life-threatening state, because they truly are, regardless of their general appearance.
Kids are unpredictable
Children in a DKA state have unpredictable presentations and are more susceptible to cerebral edema, the most serious of the secondary complications. In fact, the risk of cerebral edema is greater than 1 percent in all newly diagnosed cases. Approximately 2 percent of all children in moderate to severe DKA die from the disease. Additionally, the mortality rate is 25 to 30 percent, with permanent neurological deficits occurring in more than 35 percent of the survivors.
Twenty to 40 percent of children admitted to the hospital for DKA possess symptoms that are indicative of insulin-dependent diabetes mellitus (IDDM) and are soon thereafter diagnosed as an insulin-dependent diabetic. The classic triad of clinical presentations for DKA includes excessive thirst (polydipsia), excessive urination (polyuria), and weight loss (polyphagia – unusual in child). Additional symptoms include flu-like symptoms, abdominal pain, vomiting, altered respiratory patterns including respiratory distress, tachypnea, or deep respirations (Kussmal Respirations), general symptoms of shock, altered mental status, and possibly a fruity or acetone odor on their breath.
The management of children with DKA first and foremost includes the identification of a potentially life-threatening malady despite the obvious signs and symptoms. Initial treatment includes ABCs, vital signs, and blood glucose levels. Field blood glucose monitors may be unable to read extremely high levels or may indicate an error in processing. This single vital may be the single most important sign that DKA is a possibility. Fluid resuscitation at 20 ml/kg over the first hour is advised, with recommendations that extreme caution be taken to not fluid overload the patient, as renal complications are common. Supplemental oxygen must be provided to assist in the correction of the acidosis. No pharmacological agent should be given until specific laboratory values can be evaluated. Treatment must be supportive in nature and flexible, as changes in the patient's mental status can occur at any time.
Sugar is not a panacea
Some EMS education manuals and instructors continue to follow the incorrect and potentially negligent treatment cliché, "When in doubt, give sugar!" If there is confusion as to whether the child is cool, "clammy," and pale versus flushed, dry, and warm with any of the three poly's, DO NOT give glucose! If you can’t tell the difference, simply provide baseline care and transport the child to a definitive care facility.
In conclusion, the child suffering from DKA may have a variety of signs and symptoms inconsistent with those seen in the adult. Be prepared. Provide a strong assessment, ABCs, and any supportive care indicated. Be careful to not be overly aggressive with fluid resuscitation. Pharmacological interventions are rarely needed in the prehospital setting and should not be considered without specific indication and medical direction. DKA is a potentially lethal condition that can be mistaken for other maladies. The goals in treating this child are restoring perfusion, slowing or stopping the advancing acidosis within the scope of the prehospital practitioner, avoiding causing unnecessary complications, and safely transporting the child to a facility with pediatric capabilities.