A 7-year-old girl with diabetic ketoacidosis develops headache, bradycardia with rising blood pressure, and a drop in Glasgow Coma Scale from 15 to 10 three hours after starting intravenous fluids and insulin. Which is the most appropriate immediate treatment?

• A Mannitol 0.25 to 1 g/kg intravenously ✓
• B Intravenous furosemide 1 mg/kg
• C Immediate reduction of insulin infusion rate alone
• D Hyperventilation to a PaCO2 of 25 mmHg as definitive therapy

Explanation

Headache with bradycardia, hypertension, and falling consciousness is cerebral edema, the leading cause of DKA-related death in children. Mannitol 0.25 to 1 g/kg given over 20 minutes is the recommended immediate therapy, with hypertonic saline as an alternative. Slowing insulin does not reverse established edema, furosemide has no role as first-line therapy, and intubation with hyperventilation is reserved for impending herniation because aggressive hyperventilation itself worsens cerebral ischemia.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.