Diabetic Ketoacidosis

Criteria:

  • Elevated glucose

  • Acidosis

  • Decreased bicarb

  • Elevated anion gap

  • Elevated ketones

Patients present with elevated glucose on triage. The majority of the time this will just be

hyperglycemia, but DKA/HHS must be ruled-out.

  • Order BMP, mag, phos, vbg, ketones (beta-hydroxybutyrate), and osmolality.

  • Start fluids, 2L of either LR or NS is a good choice, cheaper than plasmalyte and likely will not need more if the patient is not in DKA/HHS.

High glucose, low bicarb, elevated anion gap, acidosis, elevated ketones, and variable mental status point toward a diagnosis of DKA. High glucose, normal bicarb, normal pH, normal ketones, elevated serum osmolality, and stupor/coma point towards HHS.

Placing patients on end tidal capnography may be useful as well. End tidal capnography greater than or equal to 35 is 100% sensitive in ruling out DKA and end tidal capnography less than or equal to 21 is 100% specific to rule in DKA.

At this point continue LR or switch to plasmalyte. Patients in DKA can be in ~6L of fluid deficit. Make sure the patient has 3 good IV lines. Can switch fluids to infusion rate after first hour. The mainstay of treatment for HHS will also be continued fluid repletion.

The next step is to evaluate the potassium level. 

  • <3.5: Do not start insulin. Give potassium supplementation. 10 mEq will raise potassium level by ~0.1. Can do 10 mEq/hr per peripheral IV line, or 20 mEq/hr from central line. Can also give 40 mEq orally per hour if patient can tolerate it. 

  • 3.5-5.5: Start insulin. Start drip at 0.1 u/kg/hr. Give potassium supplementation of 20-30 mEq/hr. 

  • >5.5: Start insulin drip at 0.1 u/kg/hr. 

Additional Steps

  • Replete mag and phos as necessary. 

  • Check finger sticks hourly. Repeat chemistry every 2 hours. 

  • Once FS or glucose drops <250, start D5. Can do this by using D5-LR, D5-1/2NS, or two bag technique (can google it). Keep goal glucose between 150-200.  Run potassium with the fluids as mentioned above. 

  • Admit patient to ICU or floors as per institution guidelines.

Akash Shah, PGY4

Source: https://wikem.org/wiki/Diabetic_ketoacidosis

Myxedema Coma in the ED

Myxedema Coma is an extreme form of hypothyroidism. Consider in all patients with altered mental status, especially with symptoms including: bradycardia, hypothermia, bradypnea, dry skin, sparse hair (can have lateral eyebrow hair loss as a sign), hoarse voice, periorbital edema, or non-pitting edema in extremities. Patient will not actually be in a coma, but will be altered/confused. Mortality approaches 100% without treatment. Lab findings may include hyponatremia, hypoglycemia, respiratory acidosis (hypercapnia).

 

The diagnosis of myxedema coma will likely not be made until admission. It is important to recognize it as part of your differential diagnosis. If patients are altered, have any of the above symptoms, plus refractory shock to fluids or vasopressors, must start empiric treatment and symptomatic management (treat hypothermia, respiratory distress, etc), on top of initial ED AMS work-up.

 

Order additional labs, including TSH, free T4, random cortisol level. Give hydrocortisone 100mg IV to cover for underlying adrenal or pituitary insufficiency (give this after random cortisol is drawn - or can give dexamethasone instead, does not interfere with cortisol testing). Levothyroxine (T4) 200-400mcg IV push. Liothyronine (T3) use is controversial, can cause dysrhythmia, follow endocrine recommendations regarding its use if necessary. Theoretically, stress dose steroids should be given prior to levothyroxine so as not to precipitate any possible adrenal crisis, however levothyroxine has a slow onset so as long as both are given in a timely manner, it should not matter.

 

Patient is to be admitted to the MICU. Diagnosis will likely be made in the MICU, and definitive treatment will require treating the underlying cause. Most likely underlying cause is non-compliance with hypothyroidism medications.

 

Akash Shah, MD

Department of Emergency Medicine

Lincoln Medical Center

Bronx, NY

 

Sources:

https://emcrit.org/ibcc/myxedema

https://wikem.org/wiki/Myxedema_coma

https://litfl.com/myxoedema-coma

http://www.emdocs.net/em3am-myxedema-coma