I struggled to find PEM resources for my CT3 year, despite the variety of excellent resources out there. I hope this website will help point you in the right direction. I'm not a PEM expert, but am following the guidance CEM have issued (in the form of a syllabus) to put together this page. This page is not endorsed by CEM, and any mistakes are mine.

Please comment with corrections, additions and further suggestions.

All the information here is collected from the internet, and it might be out of date or inaccurate, so please use your judgement and adhere to your hospital's protocols. If you do notice any errors or omissions please comment so we can put them right!

To navigate, decide whether you want to start with a PMP or a PAP. You can then select which PMP or PAP you want to look at. You will then be taken to the summary page for that PMP, with links expanded topic collections. If you know what topic you want to look at already, click on the link on the right hand side.

Sunday, 26 January 2014

Hypoglycaemia in Children

As many of us treating children are first and foremost adult physicians, I suspect that hypoglycaemia in children is over treated. There are standard guidelines in EPLS and APLS - but these are generally associated with cardiac arrest rather than in isolation. Hospitals have produced their own guidelines, many of which are freely available on the intranet.

Hypoglycaemia = BM <2.6mmol/L

Signs and Symptoms
Autonomic features (warning signs):
    sweating, hunger, tingling around the mouth
    tremor, tachycardia, pallor, palpitations and anxiety.
    These warning signs may be lost in patients with repeated or prolonged hypoglycaemia.

Neurological features:
    Lethargy, tiredness, change in behaviour
    Headache, visual disturbance, slurred speech, dizziness.
    Altered level of conscious, coma, convulsions.

Causes of Hypoglycaemia
High sugar requirement
Excess insulin
Inborn errors of metabolism
Early manifestation of other serious disorders (sepsis, congenital heart disease, inter - cranial event).
Gastroenteritis  - (rare in children <5 so shouldn't be routinely analyzed at triage)
Ketotic hypoglycaemia - toddlers with lethargy or seizure following a prolonged fast. May be unresponsive in the morning.

Bloods for analysis
Oral carbohydrate challenge - unless child too unwell for this. The BNF is fantastic at recommended non pharmacological treatments first. Don't give dextrogel/ glucogel - coke, lucozade, sugar cubes, jelly babies work a lot better. Most diabetics I know would do anything NOT to have glucogel as it tastes so disgusting! Even the BNF doesn't advise it!

Bolus of IV glucose:
      EPLS dose is 5-10ml/kg 10% dextrose and 2.5ml/kg in the newborn.
      APLS has changed to 2ml/kg.
If no IV access available, give IM glucagon   0.5mg < 8 years, 1mg >8 years
IV infusion of 10% dextrose at 6-8mg/kg/min) to maintain sugar >4mmol/L

Critical Blood samples 
Should only be taken during hypoglycaemia (BSL <2.6mmol/l)
  1. Glucose and lactate: fluoride oxalate tube
  2. Insulin, C-peptide, cortisol, growth hormone: plain tube on ice
  3. Ammonia: heparinized tube on ice
  4. Ketones and free fatty acids: fluoride oxalate (BLF) tube (1ml*)
    (Do also bedside test ketones)
  5. Amino acids, electrolytes: heparinised
  6. Acid-base: capillary sample
  7. Blood drops onto a Guthrie test card (for acyl-carnitine profile)
  8. Others if required e.g. Toxicology studies (Salicylates, ethanol, sulfonylurea )
  9. Urine for ketones, glucose, reducing substances, amino acids, organic acids and maybe toxicology. 
This is summarised on a lovely chart here:

And here's my summary card, lest I ever forget which tubes to fill! 

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