Ep 146 DKA Recognition and ED Management

In this first part of our 2-part podcast on DKA and HHS, Drs Melanie Baimel, Bourke Tillmann and Leeor Sommer discuss the importance of identifying the underlying cause or trigger in DKA patients, the pitfall of ruling out DKA in patients with normal pH or normal serum glucose, how to close the gap effectively, why stopping the insulin infusion is almost never indicated, how to avoid cardiac collapse when DKA patients require endotracheal intubation, the best alternatives to plastic in the trachea, why using a protocol improves patient outcomes, how to avoid the common complications of hypoglycemia and hypokalemia, and much more... Podcast voice editing by Raymond Cho. Production, sound design & editing by Anton Helman. Written Summary and blog post by Lorraine Lau & Winny Li, edited by Anton Helman September, 2020. Cite this podcast as: Helman, A. Baimel, M. Sommer, L. Tillmann, B. Episode 146 - DKA Recognition and ED Management. Emergency Medicine Cases. September, 2020. https://emergencymedicinecases.com/dka-recognition-ed-management. Accessed [date]. Go to part 2 of this 2-part on diabetic emergencies The Difficulty in Diagnosing Diabetic Ketoacidosis (DKA) There are no definitive criteria for the diagnosis of DKA according to the 2018 Canadian DKA Guidelines. As such, it is important to have a low threshold to consider the diagnosis in any diabetic patient who presents with polyuria, polydipsia, hyperpnea, abdominal pain/nausea/vomiting or altered level of awareness. While most patients with DKA will have the triad of hyperglycemia, anion gap metabolic acidosis and ketonemia, there are important exceptions: * DKA patients can have a normal glucose (euglycemic DKA - see below) * DKA patients can have a normal pH and a normal bicarbonate (normal VBG) in the context of ketoacidosis plus metabolic alkalosis as a result of vomiting and/or the triggering illness * Negative urine ketones should not be used to rule out DKA, as urine tests measure the presence of acetoacetate, but not β-hydroxybutyrate A β-hydroxybutyrate level > 1.5 mmol/L has a sensitivity of 98-100% and specificity of 78.6-93.3% for the diagnosis of DKA in diabetic patients presenting to the ED with elevated serum glucose levels. Clinical Pearl: Many patients with DKA present with some degree of abdominal pain. Severe abdominal pain with only mild ketoacidosis argues against DKA as the cause. When in doubt about the need for an abdominal imaging, resuscitate the patient first, and perform serial abdominal examinations. Have a low threshold to image if the ketoacidosis improves but the patient continues to be symptomatic or clinically worsens. Severity categorization of DKA Differentiating DKA from Hyperglycemic Hyperosmolar Syndrome (HHS) DKA and HHS may occur concurrently. Evaluation for precipitating cause of DKA is paramount as it is often the cause of of death in patients with DKA DKA can be the initial manifestation of diabetes, but it often occurs in the context of known diabetes plus a trigger. Most often, it is due to medication non-adherence, incorrect dosing or infection. However, any physiologic stress can trigger DKA. Common causes include "The 5 I's": * Infection (pneumonia, UTI, skin, abdominal) * Infraction (MI, stroke, bowel infarction) * Infant on board (pregnancy) * Indiscretion (dietary nonadherence) * Insulin deficiency (insulin pump failure or nonadherence) In addition,