Endocrine and Metabolic Emergencies
Endocrine emergencies in children are often mistaken for gastroenteritis or sepsis. Diabetic ketoacidosis presents with polyuria, polydipsia, vomiting, abdominal pain, Kussmaul respirations, and dehydration; confirm with hyperglycemia, acidosis, and ketones. Management is methodical: establish IV access, begin isotonic fluid resuscitation for shock, then rehydrate over 24–48 hours, start an insulin infusion at 0.05–0.1 units/kg/hour without a bolus, and replete potassium as insulin drives it intracellularly. Never give bicarbonate routinely.
The critical trap: cerebral edema
Cerebral edema is the leading cause of death in pediatric DKA. Suspect it with headache, change in mental status, bradycardia, hypertension, or decreasing oxygen saturation during treatment. The response is to slow fluids, elevate the head of the bed, give mannitol 0.5–1 g/kg or hypertonic saline 3% at 5 mL/kg, and obtain emergent imaging. Rapid fluid correction is a risk factor, not a treatment.
Hypoglycemia and adrenal disease
Treat symptomatic hypoglycemia with dextrose: D10 at 5 mL/kg (2–5 mL/kg), D25 at 2–4 mL/kg, or D50 at 1 mL/kg, then recheck glucose and provide a continuous source. In a neonate with congenital adrenal hyperplasia, the salt-wasting crisis appears at 1–3 weeks with vomiting, hyponatremia, hyperkalemia, hypotension, and ambiguous genitalia in females; treat with isotonic fluid and hydrocortisone. Consider inborn errors of metabolism in a previously well neonate who decompensates with fasting or illness - check glucose and ammonia.
Rule of thumb: in pediatric DKA, slow and steady fluids plus potassium replacement prevent the fatal complication; a sudden headache during treatment is cerebral edema until proven otherwise.