Description:
Experts: Dr. Bernard Mwesigye & Dr. Umarashid Guloba
In this episode
A young type 1 diabetic patient arrives with: Restlessness, agitation, confusion (GCS 9/15)·
Vital signs: HR 146, RR 30, SpO₂ 89%, BP 186/89·
Key finding: Vitiligo patches on skin — signaling autoimmune disease (type 1 diabetes)·
History: Several days of vomiting/diarrhoea → couldn't keep food or insulin down
· Labs: Glucose 19 mmol/L, HbA1c 14%, ketonuria 3+· Diagnosis: DKA precipitated by gastroenteritis.
KEY DISCUSSION POINTS
1. Diagnosis & Differentials
· DKA confirmed (hyperglycaemia + ketones + acidosis)
· HHS ruled out (significant ketones present)
· Hypertension = symptom of metabolic crisis, not primary problem
· Sepsis considered — gastroenteritis = trigger; antibiotics started
2. The "Golden Rule" of DKA Management
NEVER give insulin if potassium < 3.5 mmol/L
· Insulin drives potassium into cells → can cause fatal arrhythmias
· Sequence: Check K⁺ → Replace if low → THEN start insulin
3. Four Treatment Pillars
Fluids 5–6L deficit; switch to dextrose when glucose < 14
Glucose Insulin 0.1 U/kg loading + infusion; reduce gradually
Electrolytes Potassium first; monitor every 2–4 hours
Acidosis Insulin stops ketones; bicarbonate almost never
4. Critical Pitfalls to Avoid
· Giving insulin before checking potassium
· Dropping glucose too fast → cerebral oedema
· Not treating the underlying trigger (infection)
· Stopping monitoring too early — patients can deteriorate rapidly
5. Euglycaemic DKA (Emerging Danger)
· Seen with SGLT-2 inhibitors (empagliflozin, etc.)
· Glucose may be normal despite full DKA
· Always check ketones in sick patients on these drugs
6. Uganda Context
· Insulin access, cost, and cold chain are major challenges
· Diagnosis possible with minimal resources: glucometer + urine dipstick + clinical exam
· Family education on warning signs and adherence is essential to prevent recurrence
Five Takeaways
1. Examine the whole patient — vitiligo signaled autoimmune type 1 diabetes
2. Four goals: Fluids → Glucose → Potassium → Acidosis
3. Potassium rule: Replace if < 3.5 BEFORE insulin
4. Find and treat the trigger — infections are the commonest cause5. Educate family — prevents the next admission
Listen to learn. Share to save lives. Mastering Emergency Care
Disclaimer: For Educational Purposes only, refer to guidelines for definitive management
Show Notes & Resources:
· Watch the Full Case Video: https://youtu.be/qZZ86tknD8k?si=Pczbbe-vqvcti80V
