Pocket Emergency Medicine (Pocket Notebook Series) 3rd Ed.

DIABETIC KETOACIDOSIS

History

• Fatigue & malaise, N/V, abdominal pain, polydipsia, polyuria, polyphagia, weight loss, AMS/HA (may be signs of cerebral edema), fever/sxs of infection (cough, URI sxs, dysuria, rash); toddlers may not present w/ classic sxs

• RFs: Infection, poor compliance w/ insulin, puberty, inadequate caregiver

Physical Exam

• AMS, tachycardia, tachypnea, Kussmaul respirations, normo- or hypotensive, delayed capillary refill, mottled, lethargy/weakness, fever, N/V, acetone on breath (metabolic acidosis)

Evaluation

• Labs: FSG, Chem 10 (elevated anion gap acidosis, pseudohyponatremia, total body K generally depleted despite lab value, ↓ phosphorus, ↓ Mg), urine/serum ketones, β-hydroxybutyrate, UA, CBC, lactate, lipase, LFTs, urine hCG, VBG; ABG if HD unstable or comatose; blood & Ucxs if febrile

• Corrected Na = measured Na + [2.4 × (measured glucose – 100)]

• Definition: Glucose >200, venous pH <7.3 or bicarb <15, ketonemia & ketonuria

• ECG: T wave changes (hyper/hypokalemia)

• Imaging: If concern for focal infection

Treatment

• Supportive: Continuous cardiac monitoring, O2 sat monitoring, 2 large-bore IVs, intubate if necessary, evaluate & treat sources of infection

• Electrolyte monitoring: Glucose fingerstick q1h (goal ≈ 150); Chem 7, Ca, Mg, phosphorus q2h

Disposition

• Admit: All pts; HD unstable, pts w/ cerebral edema/AMS or newly diagnosed diabetes pts should go to the ICU

Pearl

• Children more likely than adults to develop cerebral edema; carry a 25% mortality rate; avoid insulin bolus & large-volume isotonic fluid boluses