Diabetic ketoacidosis (DKA) is the leading cause of hospitalizations for pediatric patients with diabetes mellitus. The most severe complication of DKA is cerebral edema that may lead to brain herniation. We present a case report that highlights the subclinical presentation of DKA-related cerebral edema in a pediatric patient and review the acute care management of suspected cerebral edema during transport. Diabetes mellitus is a health care problem that has been coined an "epidemic." The estimated incidence of diabetes in the United States is 24.3 per 100,000 children per year; this approximates to 15,000 children being newly diagnosed annually. The observation that children younger than 12 months of age are being diagnosed with new-onset diabetes is also alarming because diabetes is a chronic disease into adulthood and currently is the seventh leading cause of death in the US.1 There are 2 distinct classifications of diabetes. Type 1 diabetes describes those patients who are inherently insulin deficient and must rely on lipolysis for fuel needs during times of stress. Most patients with type 1 diabetes present during childhood. Type 2 diabetes is characterized by variable degrees of peripheral insulin resistance, but these patients have inadequate cellular glucose uptake during times of stress. Patients with type 2 diabetes classically present later in life although the problem of youth obesity has been associated with earlier diagnoses during adolescence. The most serious complication of diabetes is diabetic ketoacidosis (DKA). In children with diabetes, DKA is the leading cause of hospitalizations, morbidity, and mortality.2,3 A single episode of DKA can place a pediatric patient at risk for developing cerebral edema with subsequent brain herniation. The occurrence of cerebral edema is rare, approximately 0.5% to 1% of all pediatric DKA cases. However, there is an estimated 40% to 90% mortality from DKA-related cerebral edema.2-6 Risk factors for cerebral edema include first presentation, younger age, aggressive fluid administration, administration of sodium bicarbonate or bolus insulin doses, and precipitous drops in blood glucose (> 100 mg/dL/h). Additional metabolic abnormalities at presentation, namely an elevated blood urea nitrogen and low partial pressure of arterial CO2, are also considered to be risk factors.7,8 Medical management can be lifesaving when initiated at the time of presentation and during transport. We present a case of a 4-year-old patient with previously diagnosed type 1 diabetes who presented at a local emergency department (ED) with severe DKA. The management of this child's acidosis was complicated by the clinical presentation of cerebral edema, which was later confirmed by computed tomographic imaging of the brain upon arrival at our institution. The goal is to encourage a high index of suspicion for the presence of cerebral edema and to provide clinicians a review of the management strategies for cerebral edema during the transport process.
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