Dessy

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 DIABETIC KETOACIDOSIS
• DKA is a syndrome in which insulin deficiency
and glucagon excess combine to produce a
hyperglycemic, dehydrated, acidotic patient,
with profound electrolyte imbalance
• Most commonly occurs in patient with type 1
diabetes and associated with inadequate
administration of insulin, infection, or
myocardial infarction

Rosen’s Emergency Medicine. 9th edition.

 • DKA can also occur in type 2 diabetes and may
be associated with any type of stress, such as
sepsis or GI bleeding
• Approximately 25% of all episodes of DKA
occur in patients whose diabetes was
previously undiagnosed

Rosen’s Emergency Medicine. 9th edition.

Rosen’s Emergency Medicine. 9th edition.
Harrison’s Principle of Internal Medicine. 19 th edition.
Rosen’s Emergency Medicine. 9th edition.
Harrison’s Principle of Internal Medicine.
19th edition.
Diabetic Ketoacidosis pathogenesis
 Hyperosmolar Hyperglycemic State
Definition complication of type 2 diabetes and can be a life-threatening emergency
Pathophysiology • decreased insulin action results in glycogenolysis, gluconeogenesis,
and decreased peripheral uptake of glucose
Clinical features • several-week history of polyuria ，
• weight loss
• Lethargy
• Nausea ，
• Vomiting
• abdominal pain
• Kussmaul respirations
Physical • dehydration
examination • hypotension
• tachycardia
• altered mental status

Harisson ed 19
https://medlineplus.gov/ency/article/000304.htm
http://emedicine.medscape.com/article/1914705-overview#a6
Laboratory • Plasma glucose level of 600 mg/dL or greater
features • Effective serum osmolality of 320 mOsm/kg or greater
• Serum pH greater than 7.30

Treatment • Airway management

• Fluid resusication
• IV insulin

Prognosis Older age, the presence of concurrent illnesses, and severity of the
metabolic derangements (especially dehydration) contribute to this
high mortality, as do delay in establishing the diagnosis and failure to
treat HHS aggressively from the outset also may contribute to this high
mortality rate

Complication Shock
cerebral edema
Increased blood acid level (lactic acidosis)

Harisson ed 19
https://medlineplus.gov/ency/article/000304.htm
 Clinical signs
• Signs of volume
depletion, poor skin
turgor, dry mucous
membranes, sunken
eyes, and hypotension
 Hypoglycemia
• Ppl with diabetes, blood glucose <3.9 mmol/L
confirmed diagnosis of hypoglycaemia
• Ppl without diabetes, (1) symptoms with consistent
with diagnosis, (2) symptoms associated with low
blood glucose level, (3) symptoms resolve with
glucose administration
• Renal clearance of insulin decreases with age  risk
of hypoglycemia increase in elderly
• Usually caused by complication of treatment, insulin
and sulfonlyureas
 Sign and symptoms
• Common symptoms, altered consciousness
• Divided into two broad categories:
neuroglycopenic and autonomic
• Neuroglycopenic include alterations in
consciousness, lethargy, confusion, seizures, focal
neurologic deficits
• Autonomic include anxiety, nervousness, nausea,
vomitting, palpitations, tremor
• Cholinergic manifestation may also occur
 Sepsis
• Begin early goal-directed therapy in all patients with septic
shock.
• Monitor the CVP to guide fluid resuscitation in these patients.
• Begin treatment by aggressively bolusing several liters of
normal saline to achieve a goal CVP between 8 and 12 mmHg.
• Initiate vasopressor support with a norepinephrine infusion in
patients who remain hypotensive and titrate to a goal MAP
>65 mmHg.
• Start broad-spectrum antibiotics targeted at the proposed
source and pursue s urgical drainage/debridement when
indicated.
Clinical_Emergency_Medicine_LANGE__2014_PDF__tahir99
_VRG
Extracranial infaction
Severe sepsis is sepsis with tissue hypoperfusion or organ
dysfunction as defined by the following criteria:

• Hypotension
• Lactate greater than the upper limits of normal laboratory
results
• Urine output <0.5 ml/kg/hr for > 2 hrs, despite adequate fluid
• resuscitation
• All with Pa02/FI02 <250 i n the absence of pneumonia
• All with Pa02/FI02 <200 i n the presence of pneumonia
• Creatinine >2.0 mg/dL
• Bil irubin >2 mg/dL
• Platelet count <1 00,000/µL
• Coagulopathy (INR > 1 .5)

Clinical_Emergency_Medicine_LANGE__2014_PDF__tahir99
_VRG
DENGUE SHOCK SYNDROME
Dengue Shock Syndrome
http://www.nvbdcp.gov.in/Doc/Clinical
%20Guidelines.pdf
http://www.nvbdcp.gov.in/Doc/Clinical
%20Guidelines.pdf
http://www.nvbdcp.gov.in/Doc/Clinical
%20Guidelines.pdf
http://www.nvbdcp.gov.in/Doc/Clinical
%20Guidelines.pdf
http://www.nvbdcp.gov.in/Doc/Clinical
%20Guidelines.pdf
 Bacteremia
• Bacteremia is the presence of bacteria in the
bloodstream that are alive and capable of
reproducing. It is a type of bloodstream
infection.
• Bacteremia is defined as either a primary or
secondary process. In primary bacteremia,
bacteria have been directly introduced into
the bloodstream.
• Bacteria can enter the bloodstream in a number of
different ways. However, for each major classification
of bacteria (gram negative, gram positive, or
anaerobic) there are characteristic sources or routes
of entry into the bloodstream that lead to bacteremia.
• Causes of bacteremia can additionally be divided into
healthcare-associated (acquired during the process of
receiving care in a healthcare facility) or community-
acquired (acquired outside of a health facility, often
prior to hospitalization).
 Diagnosis
• Bacteremia is most commonly diagnosed by
blood culture, in which a sample of blood
drawn from the vein by needle puncture is
allowed to incubate with a medium that
promotes bacterial growth.
• If bacteria are present in the bloodstream at
the time the sample is obtained, the bacteria
will multiply and can thereby be detected.
 Treatment
• The presence of bacteria in the blood almost
always requires treatment with antibiotics.This
is because there are high mortality rates from
progression to sepsis if antibiotics are delayed
The treatment of bacteremia should begin with
empiric antibiotic coverage. Any patient
presenting with signs or symptoms of bacteremia
or a positive blood culture should be started on
intravenous antibiotics.
 Management (Acidosis)
• Identification of the underlying cause
• If the serum pH is so severely depressed that the acidemia
itself is thought to be an immediate life threat, bicarbonate
therapy is an option
• Emergency clinicians managing patients with acid-base
disturbances should carefully monitor the serum potassium
concentration; as the acidosis resolves, the serum
potassium level will fall and may require supplementation
• Patients with DKA or lactate acidosis failed to show any
improvements and suggest increase in harmful effecs
 Management (Alkalosis)
• Based on underlying causes
• Iv fluid and electrolyte replacement for
patients with volume loss