Diabetic

KetoAcidosis
Nikitha Ashok, DO
PGY1 Emergency Medicine
Community Medical Center
• 16 yo female presented to ED with 1 day of nausea and
vomiting, FSBG in the 300s all day, unresponsive to
insulin.
• No diarrhea, abd pain, chest pain, sob, cough, fever or
lightheadedness/ fainting
• History of IDDM type 1, compliant with insulin regimen
• Visits grandfather who is COVID-19 +

HPI
• IDDM type 1, dx at 3 years of age, on Admelog and
Lantus SQ 27 units at bedtime
• Hashimoto’s thyroiditis, Levothyroxine 50 mcg
• Hyperlipidemia, d/c Lipitor
• not vaccinated against Covid-19
• Lives at home with parents, pet dog at home, visited
grandfather recently who was COVID+
• Does well at school, at appropriate grade level

PMHx/ PSHx/PFHx/Social Hx
• Vitals: Temp/ HR 157/ BP 112/91/ RR 24/ SpO2 100% RA
• AOx4, in moderate distress, skin warm, dry, no decreased turgor, dry oral mucosa,
(+) acetone odor on breath, neck supple, full ROM, (+) Kussmaul’s respirations,
(+) tachy, abdomen soft and nontender, (+) peripheral pulses, no FND
• FSBG 315
• BGM 246
• pH venous 6.91
• CO2 <10
• Ketones 80
• Anion gap >19
• POCT Upreg negative
• POCT SARS CoV2 positive
• POCT Strep negative

Physical exam/ labs/

imaging in ED
• DKA
• viral gastroenteritis
• Medication noncompliance
• Hyperthyroidism
• GI: SBO, appendicitis, cholecystitis, pancreatitis, toxic alcohol
ingestion
• GU: ovarian torsion, ruptured ovarian cyst, PID, pregnancy,
pyelonephritis
• Neuro: head trauma, meningitis, encephalitis, pseudotumor cerebri
• Carbon monoxide poisoning

DDx/ Five I’s of DKA

• FSBG, ABCs, AMS, orthostatic hypotension, dehydration
• Address dehydration/shock: NS 1L Bolus
• Address symptoms: 8mg Zofran IVP
• Dispo: PICU Dr.The contacted for admission

Critical actions in ED
• Insulin drip 0.07 U/kg/hr, adjust based on BGM
• BG q1hr
• BMP, Mg, Phos, CBG q2hrs
• BCx and Ucx negative, ID consult for T1DM with Covid
• EKG + coags, d-dimer, trop, BP monitoring
• Neuro checks q1hr- monitor for cerebral edema
• D5NS 150mL/hr

PICU course
• Patient not in DKA, BG in 200s
• VBG pH 7.33/ 32/45/17/-7.9
• Anion Gap 11
• Glucose 124-198 overnight
• Tolerating PO and transitioned to SQ
• Endo consult: elevated BG in the AM, increase home
basal dose of Lantus to 29U

Discharge from PICU

• Secondary to insulin deficiency or resistance + glucagon
excess
• Underlying inflammatory/infectious process-
catecholamine and cortisol opposes insulin
• Accelerated hyperglycemia and ketogenesis
• Hyperglycemia drives osmotic diuresis leading to
dehydration and volume depletion + electrolyte imbalances
• Pseudohyponatremia
• Potassium lost by vomiting, renal excretion

Pathophysiology
• Generalized symptoms: N/V, abdominal pain without
diarrhea or fever
• Fruity odor (acetone)
• Polydipsia, polyuria, polyphagia
• Fluid depleted: orthostatic hypotension, tachycardia,
decreased skin turgor
• Kussmaul respirations in severe cases + metabolic
acidosis
• Often develops <24 hours

Presentation
• Hyperglycemia > 250
• pH < 7.3 or bicarb <15
• Moderate ketones in U/A or serum
• AG >10
• Hyponatremia due to volume depletion
• Comorbities: five I’s
• Intoxication (methanol, ethanol, salicylates, etc)
• Order stat blood glucose after FSBG, CBC, BMP, U/A and Upreg
(FSBG q1hr, BMP q2-4hrs)
• EKG if hyperkalemia, CXR/ BCx if febrile or other infectious source

Labs
• IV access: start crystalloid boluses (LR preferred) to
correct hypovolemia and hyperosmolarity
• IV regular insulin 0.1 units/kg/hour after potassium level
comes back
• In ED, once [K+] is back, may give 10U regular insulin
IV push if drip taking a long time to come back from ED
• Run drip faster if no improvement
• Potassium replacement if < 3.5eEq/L
• Start D5NS once glucose reaches 250 mg/dL

How to manage DKA

• Ketoacidosis resolved: AG < 14
• Blood beta-hydroxybutyrate levels undetectable
• Once patient is able to eat, switch to SQ insulin with
overlapping IV insulin infusion
• Long-acting SQ insulin 2 hours before discontinuation of
IV insulin infusion
• Continue IV insulin until bicarb > 15, pH > 7.3, AG <12
• Sodium bicarb only if patient has severe hyperkalemia, in
extremis, cardiac arrest or profound shock

Resolution
• Avoid hypoglycemia: begin D5W when glucose hits <250
• Hypokalemia: check potassium prior to starting insulin,
atleast 3.3, add 20mEq potassium to each liter of
maintenance fluid after initial bolus
• Serial neuro exams q1hr for cerebral edema, rare
complication seen in children

Pitfalls
• Rare complication (0.7% - 1.0% of children with DKA)
• Caused by rapid fluid and electrolyte shifts, elevated ICP and possible
brainstem herniation
• DKA and degree of acidosis can also cause AMS, therefore if mildly
acidotic and AMS, suspect cerebral edema
• High rates of morbidity and mortality
• Clinical diagnosis: posturing, pain response, FND, Cheyne-Stokes
respirations, AMS, incontinence, vomiting after correction of DKA,
Cushing reflex
• Stop IVF, elevate head of bed
• Osmotic diuresis:
• Mannitol 0.5-1g/kg over 20-30min
• Hypertonic 3% NaCl 3-5 mL/kg IV over 15-20 min

Cerebral Edema
• Discharge with instructions to monitor glucose more
frequently
• Follow up with endocrinologist, may need dose
adjustment

How to dispo the patient