What are the immediate steps for a child with a history of diabetic ketoacidosis (DKA) controlled on subcutaneous insulin who suddenly experiences cardiac arrest?

Cardiac Arrest in a Child with DKA on Subcutaneous Insulin: Causes and Immediate Management

Immediately initiate high-quality CPR with chest compressions at least one-third the anteroposterior diameter of the chest at 100-120/minute, using a 15:2 compression-ventilation ratio with two rescuers, while simultaneously identifying and treating the most likely reversible causes: severe electrolyte abnormalities (particularly hypokalemia and hypophosphatemia), cerebral edema, or profound metabolic acidosis. 1, 2

Immediate Resuscitation Protocol

Start CPR immediately if the child has no pulse or is not breathing normally 1:

• Compression technique: Push hard (at least one-third of chest depth) and fast (100-120/minute) with complete chest recoil 1
• Compression-ventilation ratio: 15:2 when two rescuers are present; 30:2 if alone initially 1
• Minimize interruptions: Change compressor every 2 minutes to prevent fatigue 1
• Attach monitor/defibrillator as soon as available to identify rhythm 1, 2

Drug Therapy During Resuscitation

Administer epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL concentration, maximum 1 mg) as soon as vascular access is obtained, and repeat every 3-5 minutes 1, 2:

• Do NOT use atropine in pediatric cardiac arrest—it is not evidence-based and delays appropriate epinephrine administration 2
• Continue high-quality CPR while establishing IV/IO access 1

Most Likely Causes of Cardiac Arrest in DKA

1. Severe Hypokalemia

• DKA treatment with insulin drives potassium intracellularly, causing life-threatening hypokalemia 3, 4
• Hypokalemia causes cardiac arrhythmias and can precipitate cardiac arrest 3
• Critical pitfall: Failure to monitor and replace potassium during DKA treatment 3

2. Severe Hypophosphatemia

• Aggressive insulin therapy without phosphate monitoring can cause profound hypophosphatemia 4
• Severe hypophosphatemia leads to respiratory failure, cardiac dysfunction, and cardiac arrest 4
• One case report documented cardiac arrest in a 14-year-old with DKA who developed severe hypophosphatemia within 16 hours of treatment 4

3. Cerebral Edema

• Rapid overcorrection of hyperglycemia with fluids and insulin can cause cerebral edema, seizures, and death 3
• Cerebral edema can lead to herniation and cardiorespiratory arrest 3, 5
• Risk factors: Overly aggressive fluid resuscitation and rapid glucose correction 3

4. Profound Metabolic Acidosis

• Severe acidosis (pH <6.9) can cause hemodynamic collapse and cardiac arrest 3
• Metabolic acidosis impairs cardiac contractility and vascular responsiveness 3, 6

5. Other Electrolyte Abnormalities

• Hypomagnesemia and additional electrolyte disturbances frequently occur in DKA 3
• Multiple concurrent electrolyte abnormalities increase arrhythmia risk 3

Rhythm-Specific Management

If rhythm check reveals asystole (non-shockable rhythm) 2:

• Resume CPR immediately without attempting defibrillation 2
• Do NOT waste time attempting to shock asystole—this delays effective CPR and has no benefit 2
• Continue epinephrine every 3-5 minutes 2

If rhythm is shockable (VF/pulseless VT) 1, 2:

• Deliver 1 shock immediately 1
• Resume CPR for 2 minutes before next rhythm check 1
• Continue until advanced life support arrives or child shows signs of life 1

Critical Monitoring and Correction During Resuscitation

While CPR continues, the team must simultaneously address reversible causes 3, 4:

• Check potassium immediately: Replace aggressively if low 3
• Check phosphate levels: Severe hypophosphatemia requires urgent correction 4
• Assess for cerebral edema: Look for signs of increased intracranial pressure 3
• Monitor glucose: Avoid overly rapid correction 3
• Consider bicarbonate only if pH <6.9 or in peri-intubation period to prevent hemodynamic collapse 3

Key Pitfalls to Avoid

• Never delay CPR to obtain additional history or labs—start compressions immediately 1, 2
• Never use atropine in pediatric cardiac arrest 2
• Never attempt defibrillation for asystole—this wastes critical time 2
• Never overlook electrolyte monitoring during DKA treatment, particularly potassium and phosphate 3, 4
• Never correct hyperglycemia too rapidly—this increases cerebral edema risk 3