Dodge Flashcards
describe the Symptoms of Ketoacidosis
nausea
vomiting
polyuria
polydipsia
polyphagia
abdominal pain
dyspnea
describe physical exam findings of ketoacidosis
tachycardia
hypotension
decreased urine output
tachypnea/kussmaul respirations
abdominal tenderness
altered mental status: lethargy, obtundation, coma
describe the diagnostic criteria for diabetic ketoacidosis
- Serum glucose > 250 mg/dl
- Serum bicarbonate < 18mEq/L
- Presence of SERUM KETONES (more accurate representation of body ketone levels than urine
- Serum pH < 7.3
-
Anion gap will be increased due to ketoacids (results in neutralization of bicarbonate) (10-12)
- potentialy from lactic acidosis as well as infection (etc)
What is the CAUSE of DKA
- Since this a rrelative or absolute deficiency in INSULIN - need to find out why there has been a change
- work up of DKA is incomplete without attempting to determine inciting event
What are The “I’s” of DKA
- Infection
- Infarction
- Ischemia
- Intoxication
- impregnation
- idiocy
What is pertenint history of DKA
Recent sick contacts
illnesses
medication compliance
sexual activity (both infection and pregnancy)
cough, fever, sweats, diarrhea
chest pain (get an EKG)
drug use
TX of DKA (fluid resuscitation)
- Patients are DEHYDRATED (diuresis, vomiting, etc)
- replace fluids initially with .9% NaCl solution
- may require many liters depending on severity
- initial bolus of 2-3 liters of fluid over the first 1-3 hours and reassess as you go (NEED to KEEP ON RECHECKING!!!)
- will need to change to 5% dextrose in .9% or .45% NaCl once serum glucose is <200mg/dL
DKA tx (INSULIN)
- INSLUIN REQUIRED to reverse/treat DKA
- Short acting insulin (2 options)
- bolus of .1 unit/kg then .1 units/kg/hr continous insulin infusion
- .14 units/kg/hr continuous infusion (NO BOLUS)
- follow the serum or fingerstick glucose every hour to adjust insulin infusion
- once DKA is resolved can transition to subcutaneous insulin (see in a few)
TX of DKA (electrolytes)
- Total body potassium levels are DEPLETED:
- transcellular shifts may fasely elevate K+
- Replace K+ before starting insulin if <3.3 mEq/L
- Serum sodium levels will be LOW
- falsely diluted from hyperglycemia (pseudohyponatremia)
- Decrease 1.6mEq/L for every 100mg/dL over 100
- Follow electrolytes and renal function every 3-4 hours during tx
When is DKA considered resolved
- serum glucose <200mg/dl
- Serum bicarbonate > 15mEq/L
- Serume pH > 7.3
- Antion gap < 12mEq/L
Can start subcutenaous insulin at this time (restart home regiment or calculate new dose
Hyperglycemia hyperosmolar syndrome (HHS)
- Type 2 >>> than type 1
- due to relative insulin deficiency or inadequate fluid intake
- hyperglycemia leds to osmotic diuresis = dehydration!!!
HHS presentation
- less severe symptoms than DKA, typically elderly
- onset over several days to weeks
- polyuria, weight loss, decreased oral intake
- altered mental status is common
- profound dehydration: hypotension, tachycardia
- Absence of nausea, vomiting, kussmaul breathing, and abdomianl pain helps differentiate from DKA
how to diagnosis HHS
- Serum glucose usually MUCH HIGHER THAN DKA
- serum glucose usually >600mg/dL (can be 1000)
- Hyperosmolarity - osmolality > 350 mosmol/L
- often pre renal azotemia/AKI: ELEVATED BUN and CREATININE
-
ACIDOSIS and KETOACIDS are absent (or mild)
- can have some starvation ketosis (urine)
- Anion Gap acidosis from lactic acid due to infection is possible
Cause of HHS
- Stroke
- Myocardial infarction
- infection/sepsis - pneumonia, etc
- Decreased fluid intake (or lack of access
TX of HHS
(fluid resuscitation)
- volume depletion/dehydration usually more severe in HHS compared to DKA
- Bolus with .9% NaCl to stabilize hemodynamics
- Then reverse free water deficit (may use .45% NaCl)
- Need to monitor electrolytes with volume replacement
GIVE THEM FLUIDS!!! NEED TONS AND TONS (very dehydrated)
