DKA CASE _ ER CASE

31-year-old woman presenting with lethargy, nausea, and vomiting with Altered mental status Pt is diabetic, 70/30 Insulin suspension BID Nausea and vomiting for the past 24 hours and has been unable to eat during that time Pt hasnt had insulin for the past 24 hours Vitals a. Temp 38 b. HR 120 c. BP 100/60 Differential Dx a. DKA b. Sepsis(febrile) c. Acute Pancreatitis d. Bowel Obstruction Order Sheet a. OXY b. VITALS MONITOR every 1 hour c. IVA d. NPO e. CARDIAC MONITOR f. FINGER STICK GLUCOSE g. ACETAMINOPHEN h. PHENERGAN i. HCG j. ABG Focus PE Order Sheet a. NPO until gap closes b. NSS c. INSULIN regular iv continous d. FINGER STICK GLUCOSE every one hour due to insulin SE hypoglycemia e. CBC f. BMP every 3 to 4 hours g. LFT h. LIPASE i. AMYLASE Pancreatitis can precipitate DKA j. SERUM OSMOLALITY k. KETONE BODIES IN SERUM l. U/A m. HCG n. URINE CULTURES o. BLOOD CULTURES p. CXR q. ECG Interval Follow Up a. Glucose getting better example 266 Order Sheet 1. Change liquids to Change liquid to D5+NSS Change Location to ICU Order Sheet 1. NPO 2. Bed Rest 3. Measure Urine Output 4. ABG each 2 hours 5. BMP each 4 hours 6. Normal Saline iv continouous (after 4 hours) Advance exam for next available exam a. BMP important Pseudohyponatremia resolves once glucose comes back to normal b. ABG metabolic acidosis compensated by respiratory acidosis , Increased Anion Gap Always increased AG due to the presence of ketones No increased AG no Dx of DKA c. U/A

a. b.

Positive for Infection Ketones

Order Sheet a. ANTIBIOTICS (iv) a. Levofloxacin or Ampi + Genta b. BMP Every 2 hours c. MAGNESIUM d. PHOSPHORUS e. URINE CULTURES

Follow Up Interval a. BP is improving b. Pt is still lethargic (Neuro is check in the PE) c. Glucose is 266 Change liquid to D5+NSS d. If K falls and Phosphorus is low You can start Potassium Phosphate e. If gap close and ONLY ONCE it close Start Diet Cancel NPO Cancel IV Insulin Start Lantus Insulin Start Lispro Three hours after you can cancel Insulin IV Counseling if there is time a. Follow up appointment in 4 weeks b. HbA1c c. Podiatric Consult d. Ophtalmology consult Diagnosis: DKA DKA Criteria: Glycemia over 250 Low bicarbonate (below 15) Elevated anion gap Elevated ketonemia Amylase and Lipase might high (do not confuse with pancreatitis) Usually restore intravascular volume with 5-6 Lts_ 2 Lt as bolus, _ 500 ml/hour per first 4 hours, _ 250 ml/hour after Once pt improves, BP and good urine output, change saline normal saline KCL Indication: K less than 5.3, no ECG changes, normal renal function Hyperosmolar Hyperglycemic State: Glucose over 600 Osm greater than 330 Absent ketonemia No Acidosis