Pediatric emergency medicine trisk 465

Management is similar to hypernatremic dehydration with initial reexpansion of
intravascular volume, then repletion of maintenance over 48 hours
Syndrome of Inappropriate Antidiuretic Hormone Secretion
Associated with bacterial meningitis (50%), positive pressure ventilation (20%),
Rocky Mountain spotted fever (70%), and numerous other illnesses
For severe lethargy, seizure, or coma administer 3% saline emergently (3 mL/kg
every 10 to 20 minutes as needed), consider furosemide, initiate antiepileptic drugs
if indicated, and treat underlying cause
Hyperparathyroidism
Uncommon in children
Family history is important as hyperparathyroidism is associated with MEN I, II and
being an infant born to a mother with hypoparathyroidism
Demineralization and bone resorption seen on x-ray
Hypoparathyroidism
Rare in children but tends to be associated with familial autoimmune syndromes,
immunologic deficiencies, or iatrogenic etiologies
Rickets
Rickets is caused by inadequate dietary intake of vitamin D; incidence is
decreasing as increased awareness and increased supplementation in food
Failure of calcification affects those parts of the skeleton that are growing most
rapidly or that are under stress; a clinical diagnosis that is confirmed by radiology
Thyroid Storm
Thyroid storm is the fulminant intensification of hyperthyroid state
Precipitated by intercurrent infection, trauma, or after subtotal thyroidectomy with
an inadequately prepared patient
Presence of high fever (often to 105.8°F [41°C]) is primary distinguishing feature of
thyroid storm from hyperthyroidism
Marked increase in cardiac workload may result in high-output heart failure,
systemic hypotension, and pulmonary edema rather than classic systemic
hypertension
Neonatal Thyrotoxicosis

Neonatal thyrotoxicosis is a life-threatening condition found in 1% to 5% of infants
born to mothers with history of hyperthyroidism; mother’s thyroid disease does not
have to be active during pregnancy
Congenital Hypothyroidism
Increased incidence of ED visits for congenital hypothyroidism now that infants are
being routinely screened at birth
Untreated disease may result in impairment of neurologic development. See Table
89.1 .



TABLE 89.1
SUMMARY OF CLINICAL FEATURES, INVESTIGATIONS, AND INITIAL
TREATMENT OF PEDIATRIC ENDOCRINE EMERGENCIES


Condition

Major clinical
features

Diabetic ketoacidosis

Polyuria, polydipsia, Blood glucose, pH
dehydration,
ketotic breath,
hyperpnea,
nausea, vomiting,
abdominal pain,
coma

0.9% saline 10
mL/kg in first
1–2 hrs IV;
insulin infusion
0.1 Unit/kg/hr;
later, may need
KAcetate 10–60
mEq/L and
KPhos 10–20
mEq/L

Hypoglycemia

Older child : hunger,
sweatiness,
dizziness,
convulsions, coma
Neonate : apnea,
hypotonia,
hypothermia,
irritability, tremor,
convulsions
Ambiguous genitalia
in females; poor
feeding, weight
loss, irritability,
vomiting,
dehydration
Nausea, vomiting,

abdominal pain,
weakness,
malaise,
hypotension,
dehydration,
hyperpigmentation

25% dextrose 1–2
mL/kg IV bolus
or 10% dextrose
5–10 mg/kg/min
IV infusion,
glucagon 0.5–1
mg IM stat (if
hyperinsulinism)

Congenital adrenal
hyperplasia

Adrenal insufficiency

Hypercalcemia
Headache,
(hyperparathyroidism)
irritability,
anorexia,
constipation,
polyuria,
polydipsia,
dehydration,

hypertension

Urgent investigations

Blood glucose
Serum for growth
hormone, cortisol,
insulin; first-voided
urine for organic
acids and toxin
screen

Initial treatment

Plasma sodium,
0.9% saline 20
potassium, glucose,
mL/kg in first
17hour IV;
hydroxyprogesterone;
hydrocortisone
karyotype and pelvic
25 mg IV stat
ultrasound
(neonatal dose)
Plasma sodium,
Hydrocortisone
potassium, glucose,
100 mg IV stat;
cortisol, and ACTH

10% dextrose in
(for retrospective
0.9% saline 20
confirmation of
mL/kg in first
diagnosis)
hour
Plasma calcium,
phosphate

0.9% saline at two
to three times
maintenance
rate; furosemide
1 mg/kg