DKA

Question 1

Airway

Answer 1

vomit, ketotic breath

Question 2

Breathing

Answer 2

Look: increased respiratory effort, Kaussmal breathing (laboured breathing - hyperventilating due to acidosis)
Listen: lung sounds
Feel: expansion, tracheal deviation

RR, O2

CXR
ABG: lactate, electrolytes, glucose, ketones

Question 3

Circulation

Answer 3

Look: dehydrated
Listen
Feel: CRT (decreased), pulses

BP, HR - tachycardia

Investigations:
1. ECG: hyperkalaemia!
2. 2 large bore cannulae
3. Bloods: FBC, UEs, LFTs, CRP, VBG
4. Blood cultures might have infective trigger
4. Temperatur
5. Catheter to monitor urine output

Issues/ dagnosis:
1. Low pH <7.3 / bicarb < 15 mmol/L
2. High glucose > 11mmol/L
3. Ketones > 3mmol / L on VBG or 2+ urine

Question 4

Disability

Answer 4

PEARL
GCS may be reduced - drowsy, confused
Neurology
BM very high

Question 5

Exposure

Answer 5

Inspect: insulin injection sites, insulin pump
Rashes
Abdo exam (pain)
Urine dip
Calves

Question 6

Management of DKA

Answer 6

1. 0.9% NaCl fluids
2. 50 units Insulin Actrapid to 50mL NaCl and infuse continuously at 0.1 unit/kg/hour

TARGET: fall in ketones, 0.5 mmol/L/hour OR rise in venous bicarbonate
If not achieving, increase insulin infusion

3. Once Glucose is <14 mmol/ L add 10% dextrose at 125ml/hour
4. Continue fixed -rate insulin infusion until ketones < 0.6 mmol/L, pH>7.3

Monitoring
* check VBG at 1,2,3 hours
* blood glucose and ketones hourly