ED Pathway for Evaluation/Treatment of Children with Type 1 DM
and Acute Illness
Goal:Clear urine ketones using rehydration and 2 doses of subcutaneous
short-acting insulin given 2 hours apart
Labs:Initial glucose, BMP, urine dipstick
Check bedside glucose, urine dipstick every 2 hrs prior to each insulin dose
Insulin:Use subcutaneous short-acting insulin only (Aspart)
Stop patient's insulin pump
Administer 10% of the patient's total daily dose (TDD) for each insulin dose
IF TDD unknown, estimate TDD to be one unit per kg body weight
Hydration:PO is preferred
Consider Zofran if vomiting
Consider NS bolus if clinically dehydrated or persistent vomiting
Patient to drink 1 ounce per age in years per hour
Blood sugar > 240
Blood sugar 200-240
Blood sugar < 200
Sugar free fluids
1/2 sugar free + 1/2 sugar containing fluids
Sugar containing fluids
Inability to tolerate oral fluids
Persistence of moderate/large ketones
after 2 doses of short-acting insulin

Posted: June, 2010
Revised: September, 2011
Authors: C. Jacobstein, MD, A. Palladino, MD, J. Lavelle, MD