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November 2024; Volume 13, Issue 11
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Utah Emergency Medical Services for Children
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Pedi Points
Tia Dickson RN, BSN
PCH Trauma RN, Utah EMSC Nurse Clinical Consultant
The holidays are a good time to discuss hypo- and hyperglycemia in kids with diabetes. While eating sugar doesn’t cause diabetes, increased sugar consumption can worsen symptoms in children who have diabetes but haven’t been diagnosed yet. EMS may respond to diabetic emergencies, as both newly diagnosed and established patients are at higher risk for hyperglycemia and DKA when sugary treats abound.
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The Highs and Lows of Diabetes
Stuti Das, MD
Primary Children’s Hospital, Unvi
Excerpts from September 9th, 2024 PETOS
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In the United States, 38 million people have diabetes, that’s about 1 in every 10 people. 1 in 5 people don’t know they have it.
In diabetes, the body has trouble using sugar (glucose) for energy.
The pancreas plays a crucial role in managing blood sugar levels in the body. It produces hormones like insulin and glucagon. Insulin helps lower blood sugar by allowing cells to take in glucose for energy, while glucagon raises blood sugar by signaling the liver to release stored glucose when levels are too low.
When you eat, the pancreas releases insulin to help move sugar from your blood into your cells.
Other organs also help regulate blood sugar. The liver stores glucose and releases it into the blood when needed. The muscles and fat cells use insulin to absorb glucose, which helps keep blood sugar levels steady. Together, the pancreas and these organs work like a team to keep blood sugar in a healthy range.
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In diabetes, the normal processes of blood sugar regulation change significantly.
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In Type 1 diabetes, the immune system mistakenly attacks and destroys the insulin-producing cells in the pancreas. This means the body can’t produce insulin, so glucose builds up in the blood, leading to hyperglycemia. People with Type 1 diabetes need to take insulin from outside the body to help control their blood sugar levels.
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In Type 2 diabetes, the pancreas still makes insulin, but the body doesn’t respond to it as effectively (this is called insulin resistance). Over time, the pancreas may also produce less insulin. As a result, glucose stays in the bloodstream instead of entering the cells, causing high blood sugar levels. Type 2 historically was seen in middle age but with increases in obesity it is becoming more common in childhood.
Overall, these changes make it harder for the body to keep blood sugar levels balanced.
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When someone has hypoglycemia, or low blood sugar, it means there isn’t enough glucose in the blood for the body to use. This can happen if a person takes too much insulin, skips meals, or exercises too much without eating. Illness, stress and overexcitement in young children can also lead to hypoglycemia.
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Hell stick is the preferred method used for blood sampling in infants and newborns, particularly when they are younger than 6 months old.
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Finger prick is preferred for older children and adults
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The blood glucose level (measured in mg/dL) that indicates hypoglycemia can vary based on a person’s age. Generally, hypoglycemia is often defined as a blood glucose level below 70 mg/dL for adults, but for children and infants the numbers below are a better predictor. It’s important to understand these age-dependent values when assessing blood sugar levels in different populations.
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The symptoms above are those you may see in a child that is hypoglycemic. In infants, symptoms can be less specific, so caregivers should be observant for any unusual behavior or signs of distress. If hypoglycemia is suspected, it’s important to quickly provide a source of fast-acting sugar.
The treatment pathway for hypoglycemia differs if you patient is alert or not.
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Patient is alert and can swallow
Use the 15-15 rule
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Give 15 grams of carbs, then wait 15 minutes
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Recheck the blood sugar, If it’s less than 70 mg/dL, repeat this process.
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Once this process has brought the blood sugar back into the target range, have the child eat a balanced snack or meal with protein and carbs.
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Infants may need less than 15 grams to achieve correction.
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The 15 grams of carbs should come from simple sugars, like juice, candy or glucose gel, as fiber (like in fruit) or protein (like in dairy) can slow absorption.
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Patient is unable to swallow or is unconscious
Glucagon IM or Dextrose IV
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Hyperglycemia, or high blood sugar (greater than 200mg/dL), happens when there’s too much glucose in the blood. This can occur if a person doesn’t take enough insulin or eats too many sugary foods. The symptoms of hyperglycemia come on more slowly than those in hypoglycemia.
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Diabetic Ketoacidosis (DKA)
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DKA is something that can happen when someone with diabetes, especially Type 1 diabetes, doesn’t have enough insulin in their body. Without enough insulin, sugar builds up in the blood, and the body starts to use fat for energy instead. When fat breaks down, it makes ketones.
If the ketones build up too much, it can make the blood very acidic, which can be dangerous. The primary signs of DKA are:
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Feeling very thirsty
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Going to the bathroom a lot
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Feeling really tired
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Stomach pain
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Vomiting
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Fruity odor to their breath
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Breathing fast or deep (like they can’t get enough air) – Kussmaul breathing
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Changes in mental status
DKA needs to be treated right away, usually in the hospital, to bring the blood sugar and ketones back to normal levels. Hospitals will administer insulin therapy, electrolyte balancing, and treatment of any underlying problems.
While transporting, EMS may consider starting a saline fluid bolus:
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Hyperosmolar Hyperglycemic State (HHS)
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Hyperosmolar Hyperglycemic State (HHS) is a serious medical condition that occurs when blood sugar (glucose) levels become extremely high and the body becomes severely dehydrated, but without the buildup of ketones. HHS typically happens in people with Type 2 diabetes when their blood sugar levels rise to dangerously high levels, often above 600 mg/dL (normal is about 70-130 mg/dL). When blood sugar levels get this high, the body tries to get rid of the excess sugar by flushing it out through the urine, which leads to severe dehydration.
Although it’s rare, HHS can occur in children, especially if:
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The child has Type 2 diabetes, which is not diagnosed or managed well.
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The child is severely dehydrated (from illness, vomiting, or diarrhea), which can make the blood sugar levels go even higher.
Keeping blood sugar under control and staying hydrated are key to preventing both HHS and DKA.
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Both hypo- and hyperglycemia can be life-threatening if not treated properly. EMS will want to move quickly to stabilize the patient and prevent further complications.
History taking
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What medications does this patient have access to?
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Have they been ill recently
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Are they restricting their diet?
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Alcohol ingestion?
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Is this a self harm event?
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Do they have a diabetes? It is well controlled?
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Could this be new onset diabetes?
For Hypoglycemia: The main priority is quickly raising the blood sugar safely, using oral glucose if the person is awake or IV dextrose/glucagon if unconscious. Any patient at risk for prolonged or recurrent hypoglycemia should be transported.
For Hyperglycemia: EMS focuses on identifying the cause of the high blood sugar (like DKA or HHS), ensuring hydration, monitoring vitals, and transporting the patient to the hospital.
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Skills refresher:
Dextrose tips & tricks
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For additional guideline direction check out the UPTN website or the new app, “Utah PTN” on android and apple devices.
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CME credit for this issue
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Training officers may review the topic above as a team training AND perform a simulation/skills check as directed. Once complete, send a roster of participants to Utah.PETOS@gmail.com and those listed will be issued 1-hour of CME credit from the Bureau of EMS, DPS.
Individuals who don’t have a training officer can get CME credit on their own by viewing a PETOS presentation in our archives and completing the instructions on the webpage.
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Skills checking
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Review the newsletter content with your team.
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Watch both video links above.
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Use the dextrose you carry and discuss dilution and administration based on your protocols.
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Upcoming CSN Webinar
LGBTQ+ Youth Data from YRBS and Beyond, Wednesday, November 20, 2024 11a-12p MST
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Our HRSA rep, Melissa Esmero, visited Utah EMSC
Utah’s HRSA representative for Utah visited from October 15-17th. We were able to show up our program and exchange ideas for overcoming barriers. We are glad to have wonderful support at the federal level.
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EMSC Pulse
National EMSC has a newsletter filled with fantastic pediatric information, resources, and links. Check it out!
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Congrats to our famous FAN
Jeff Wilson was awarded the Spirit of Service Award last month. Congratulations to the 2024 Governor’s Spirit of Service Award winners!
”Service is not only an integral part of our administration, but it’s part of who we are as Utahns. When we do something good for others, we enrich our own lives. These individuals are great examples of fostering empathy and community, reminding us that we’re all brothers and sisters. Lt. Governor Deidre Henderson and I were honored to recognize them today”
-Gov. Spencer Cox
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Autism awareness training (agency and hospital)
If your agency is interested in the John Wilson Autism Training or in receiving the free autism kits, contact Jeff Wilson, PM @jeffwilson122615@gmail.com.
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Do you know about the Medical Home Portal?
The Medical Home Portal is a unique source of reliable information about children and youth who have special health care needs (CYSHCN) and offers a “one-stop shop” for their:
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PECC development
For Utah hospital and EMS Agency PECCs
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Priming for respiratory season
From Colorado EMS for Children
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Understanding the PECC role
For hospital PECCs
For EMS PECCs
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PECC quarterly meeting
You will receive an invitation with the link through email. If you are a PECC and don’t receive this invitation contact our program manager, Jared Wright jaredwright@utah.gov.
When?
Tuesday, Nov 19, 2024, 10:00 AM
Southern PECC workshop
PECCs are encouraged to attend an in-person PECC workshop each year to receive up-to-date pediatric training, direction for your PECC role, and to participate in networking with other PECCs statewide. These workshops are free to designated hospital and agency PECCs. We will offer one in the northern part of Utah and one in the southern part each year.
When?
TBA March 2025
Where?
St. George, Utah
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Pediatric education from Utah EMSC
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Pediatric Emergency and Trauma Outreach Series (PETOS)
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PETOS (pediatric emergency and trauma outreach series)
This course provides 1 free CME credit from the Office of Emergency Medical Services, DPS for EMTs and Paramedics. The lectures are presented by physicians and pediatric experts from Primary Children’s Hospital. The format is informal; inviting questions and discussion.
Upcoming topics
November 11th, 2024 – Pediatric shock with Sarah Becker, DO
December 9th, 2024 – Pediatric seizures with Maija Holsti, MD
January 13th, 2025 – Hangings with Stuti Das, MD
02:00 PM Mountain Time (US and Canada)
Join Zoom Meeting
https://zoom.us/j/98193757707?pwd=UzdNeXppQUdtZ01KZUp2UFlzRk9vdz09
Meeting ID: 981 9375 7707
Password: EmscPCH
Archived presentations can be viewed and also qualify for CME credits. You can access them at https://intermountainhealthcare.org/for-professionals/PETOS.
To obtain a completion certificate—follow the instructions on the website
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Other pediatric education for all
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Children’s EM-mersion webinar series
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Intermountain Children’s Health Emergency Management Team is offering a weekly (every Tuesday) 30-minute educational opportunity for all hospital-based EM’s and PECCs in Utah and the surrounding Intermountain West.
We will delve into different pediatric planning topics such as decontamination operations, reunification, behavioral health, isolation/quarantine, and more! The goal is to help you better plan for pediatric patients at your facilities!
This weekly series is designed for you to attend whenever you can—you do not need to attend all sessions.
Register here for the rotating topic schedule.
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University of Utah pediatrics ECHO 2024
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The Pediatrics ECHO is back! For those new to Pediatrics ECHO, you can earn CME for participating in a case-based learning session with experts in a variety of pediatric topics.
You can view previous session recordings and other programs on the Project ECHO page. CME is available for participation in these classes.
More Information
Note the University has a new EMS education website.
When? Wednesdays 12 – 1 pm (MT)
November 13, Long COVID, Melanie Hoppers, MD
November 20, Congenital Cytomegalovirus (cCMV), Stephanie McVicar, MS December 4, Hemophilia, Jessica Meznarich, MD
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University of Utah injury prevention learning series
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University of Utah’s EMS trauma grand rounds
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Hospital-focused pediatric education
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Primary Children’s pediatric grand rounds
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Offered every Thursday, September-May
Offering both RN and MD CME
The pediatric grand rounds weekly lecture series covers cutting-edge research and practical clinical applications, for hospital and community-based pediatricians, registered nurses, and other physicians and practitioners who care for children of any age.
The series is held every Thursday, 8 a.m. to 9 a.m. from September through May in the 3rd Floor Auditorium at Primary Children’s Hospital and at Lehi a broadcast will be held in the Modersitzki Family Education Center: First floor in rooms 1 & 2.The lectures are also broadcast live to locations throughout Utah and nationwide. Click on this link to view the broadcast: https://www.youtube.com/channel/UCNQP-M_3-PdPDvnICr2Fjpg
Connect live
Click here for the PGR PCH YouTube channel to find the live broadcast. Archives (without continuing education credit) will be posted here within 1 week of the broadcast.
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Emergency Medical Services for Children Utah, Bureau of EMS, Department of Public Safety
The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system.
Email: tdickson@utah.gov
Website: https://ems.utah.gov/
Phone: (801) 707-3763
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