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EMS A to Z: Diabetic Ketoacidosis
EMS A to Z: Diabetic Ketoacidosis
Show Notes:
From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn
What is DKA?
Diabetic ketoacidosis is a metabolic state in which either a lack of insulin (Type 1 Diabetes) or resistance to insulin (Type 2 Diabetes) prevents the body from using glucose for energy. When that happens, the body must use alternate energy sources, such as fatty acids. This type of metabolism produces acidic ketones. When you put all of this together, you get elevated blood sugar, elevated ketones, and an acidic blood pH.
Who is at risk for DKA?
DKA is more common in Type I diabetes, in which patients do not produce enough of their own insulin. It can also occur in Type II diabetes. In Type II diabetes, patients typically still make insulin, but their tissues are resistant to it. Another process that can occur in Type II diabetes is something called HHS – hyperosmolar hyperglycemic state. HHS has even higher blood glucose levels than DKA, raises the blood osmolality, and can result in severe dehydration. It doesn’t have the ketone production or acidosis typical of DKA.
What are some common causes of DKA?
Insulin noncompliance / underdosing
Infection
MI
How do we identify DKA in the prehospital setting?
Typical symptoms may include nausea, vomiting, abdominal pain, possibly symptoms of a precipitating infection. If DKA is severe, altered mental status or respiratory compromise may occur.
Our assessment may reveal a patient with tachycardia, hypotension, and increased respiratory rate. You may notice signs of dehydration with dry mucous membranes, or kussmaul breathing, which is a deep, rapid respiratory pattern.
Obviously elevated glucose can clue you in as well, however there are cases of what’s known as “euglycemic DKA” when the patient is in DKA with a relatively normal BGL. This can happen if a patient is in a starvation type state, have an insulin pump, recent administration of insulin, or be taking a certain class of diabetic medications (the SGLT2 inhibitors). You can recognize them as they end in “flozin”.
How do we treat DKA in the prehospital setting?
IV fluids are the first place we start. These patients are often quite dehydrated, so volume resuscitation is the first step. In addition, there are some significant electrolyte abnormalities – namely hypokalemia – that can occur in DKA and we want to make sure that we know the patient’s acid base status and potassium levels before we initiate the other mainstay therapy in the hospital, which is obviously insulin.
What are some specific considerations in pediatric patients?
DKA can be the first presentation of diabetes in a pediatric patient. Diabetes can present in children, typically between ages 4-7, however some can present later, in the 10-14 range. We are seeing pediatric patients, more adolescents, developing type II diabetes, however it’s less likely that these kids will present in DKA.
A pediatric patient with DKA may have altered mental status, nausea, vomiting, appear dehydrated and lethargic. A blood glucose should be checked in these kids. Initiating IV fluid resuscitation is also appropriate, starting with a 10mL/kg fluid bolus.
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EMS A to Z: Diabetic Ketoacidosis
Show Notes:
From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn
What is DKA?
Diabetic ketoacidosis is a metabolic state in which either a lack of insulin (Type 1 Diabetes) or resistance to insulin (Type 2 Diabetes) prevents the body from using glucose for energy. When that happens, the body must use alternate energy sources, such as fatty acids. This type of metabolism produces acidic ketones. When you put all of this together, you get elevated blood sugar, elevated ketones, and an acidic blood pH.
Who is at risk for DKA?
DKA is more common in Type I diabetes, in which patients do not produce enough of their own insulin. It can also occur in Type II diabetes. In Type II diabetes, patients typically still make insulin, but their tissues are resistant to it. Another process that can occur in Type II diabetes is something called HHS – hyperosmolar hyperglycemic state. HHS has even higher blood glucose levels than DKA, raises the blood osmolality, and can result in severe dehydration. It doesn’t have the ketone production or acidosis typical of DKA.
What are some common causes of DKA?
Insulin noncompliance / underdosing
Infection
MI
How do we identify DKA in the prehospital setting?
Typical symptoms may include nausea, vomiting, abdominal pain, possibly symptoms of a precipitating infection. If DKA is severe, altered mental status or respiratory compromise may occur.
Our assessment may reveal a patient with tachycardia, hypotension, and increased respiratory rate. You may notice signs of dehydration with dry mucous membranes, or kussmaul breathing, which is a deep, rapid respiratory pattern.
Obviously elevated glucose can clue you in as well, however there are cases of what’s known as “euglycemic DKA” when the patient is in DKA with a relatively normal BGL. This can happen if a patient is in a starvation type state, have an insulin pump, recent administration of insulin, or be taking a certain class of diabetic medications (the SGLT2 inhibitors). You can recognize them as they end in “flozin”.
How do we treat DKA in the prehospital setting?
IV fluids are the first place we start. These patients are often quite dehydrated, so volume resuscitation is the first step. In addition, there are some significant electrolyte abnormalities – namely hypokalemia – that can occur in DKA and we want to make sure that we know the patient’s acid base status and potassium levels before we initiate the other mainstay therapy in the hospital, which is obviously insulin.
What are some specific considerations in pediatric patients?
DKA can be the first presentation of diabetes in a pediatric patient. Diabetes can present in children, typically between ages 4-7, however some can present later, in the 10-14 range. We are seeing pediatric patients, more adolescents, developing type II diabetes, however it’s less likely that these kids will present in DKA.
A pediatric patient with DKA may have altered mental status, nausea, vomiting, appear dehydrated and lethargic. A blood glucose should be checked in these kids. Initiating IV fluid resuscitation is also appropriate, starting with a 10mL/kg fluid bolus.