DKA

·          Location: Emergency room 

·          Vital signs: BP:90/60 mmHg, HR:128/min regular, Temp:100.0° F, R.R:30/min rapid and shallow   

·          C.C: Vomitings and abdominal pain. 

·          HPI: 

·          A 20-yr-old woman presents to E.R with 5 episodes of vomiting, abdominal pain, weakness and increasing drowsiness of one-day duration.  During the last 2 months she has noticed increased thirst and increased urination. The abdominal pain is diffuse, 4-5/10 in severity, constant, non-radiating and there are no aggravating or relieving factors. Vomiting is non-bloody.

1.     First quickly examine the patient 

2.     look for

3.     General: Patient is in mild to moderate abdominal pain and appears very distressed.

4.     HEENT: Very dry mucus membranes, no JVD, EOM are intact. Rest is unremarkable. 

5.     Abdomen: Soft, non tender, normal bowel sounds and no guarding or rigidity. 

6.     Pulse oximetry, stat and continuous  96% on room

7.     Oxygen, inhalation, continuous

8.      IV access, stat

9.      Cardiac monitor, stat 

10.   Normal saline, 0.9% NaCl, continuous, stat (This patient is severely dehydrated. She is hypotensive and tachycardic. So, she needs IV fluids.) 

11.   Finger stick glucose, stat  600mg/dL  

12.   Urine pregnancy test, stat  negative 

13.   CBC with differential, stat 

14.   BMP, stat Sodium is 129, Potassium is 5.0, Chloride is 90, Co2 is 14, calcium is 8.0, and a blood sugar of 600mg/dL

15.    Calcium, serum, stat 

16.   EKG, 12 lead, stat 

17.   Serum amylase, stat  mildly elevated 

18.   Serum lipase, stat  Serum Lipase WNL

19.   UA, stat UA showed 4+sugar, 2+ ketones but no evidence of infection

20.   ABG, stat ABG showed metabolic acidosis, compensated by respiratory alkalosis (pH of 7.3)  

21.   Serum osmolality, stat  305  

22.   Serum ketones, qualitative, stat   high

23.   Regular insulin, IV, continuous

24.    Phenergan, IV, one time (for nausea)

25.    Discontinue oxygen

26.   Admit the patient to the intensive care unit  

27.   NPO 

28.   Bed rest 

29.   Vitals as per ICU protocol 

30.   Urine output

31.    KCl, IV, continuous

32.   HbA1C level, routine

33.    Phosphorous, serum, stat (optional)

34.   Follow the patient with 

35.    BMP Q 2-4 hours, then Q 8-12hours, then Q day

36.    ABG Q 2 hoursx2

37.   After 4 hrs 

38.   Stop 0.9% NS and give ½ Normal saline, IV, continuous 

39.   Monitor potassium deficiency and add IV potassium chloride as needed 

40.   Consider antibiotics if the precipitating cause is an infection, get a chest X-ray, obtain blood cultures, U/A and urine cultures.

41.   Once nausea is decreased, start oral fluids. 

42.   Once the patient is stabilized transfer to ward/floor.    

43.   During discharge:   

44.   D/C IV insulin, IV fluids, cardiac monitor

45.   NPH insulin, subcutaneous, continuous

46.   Regular insulin, subcutaneous, continuous

47.   Diabetic diet (Diet, American diabetic association) 

48.   Advance diet 

49.   Counseling:

50.   Diabetic teaching

51.    Patient education, diabetes 

52.   Diabetic foot care

53.   Home glucose monitoring, instruct patient 

54.   No alcohol

55.   No smoking 

56.   Safe sex

·           No illegal drug use

·          Regular exercise

·          Seat belts use

Dr. Soryal, George