CME

7 NOVEMBER 2023
TH

EMERGENCY AND TRAUMA DEPARTMENT

HOSPITAL KUALA LUMPUR
PRIMARY TRIAGE

60 yo Lady referred case from GP for Gastritis .

Complaining of vomiting and abdominal pain for past 3 days.
Upon arrival to ED noted she looked lethargic and tachypnoic with RR of 28
Upon quick assement noted she had good pulse volume, CRT< 2 sec, pink, warm peripheries, warm to touch
What more do you want to ask?
Where was she triaged?
SECONDARY TRIAGE

 Any Allergies?
No known allergies
 Medical history?
Known case of diabetes
 Vital sign ?
BP 161/72 HR 116 RR 28 SPO2 100% T 36. 8 S PS 4
 Point of care test?
DXT 21 KET HI
CLINICAL ZONE

 60 yo lady, ADL independent , NKDFA

UL 1) DM on OHA
-
Otherwise
Missed medication for 4 day as patient is unwell
No fever
Presenting with
No chest pain
1) Upper abdominal pain x 4/7
2) Vomiting x 4/7 No dysuria
- 7 episodes a day post prandial No URTI sx
3) NBO X 4/7
4) Poor oral intake x 4/7
PHYSICAL EXAMINATION

 Alert, conscious, lethargic looking, mild tachypnoic, warm peripheries, < 2sec, good pulse
volume
 BP 161/72 HR 116 RR 26 SPO2 100% T 36.8 PS 10
 Lungs – clear
 CVS – DRNM
 Abd - So, not distended, tender over upper quadrant, bowel sound not present
 No pedal oedema
INVESTIGATIONS

 FBC WCC 14.87 HB 14.2 PLT 292

 VBG PH 6.92 HCO3 4.5 LAC 2.3 K 8.7 NA 118
 ECG Sinus tachycardia
 Investigation sent – RP, electrolytes, LFT, amylase, Coagulation profile, Urine dipstick,
 CXR erect, AXR
WORKING DIAGNOSIS?

1)SEVERE DIABETIC KETOACIDOSIS

2)TRO INTESTINAL OBSTUCTION
INITIAL INTERVENTION

1) For NPO2 3L/min, Keep SPO2 > 95%

2) For IVD Sterofundin 20 mls/kg/ 1 H – 1 L/1 H
3) IVI insulin fixed scale – 0.1 u/kg/hr = 5 u/hr
4) DXT hourly
5) For IV fentanyl 50 mcg stat
6) Insert CBD , strict I/O charting
7) Insert Ryle’s tube, for RT free flow
CLINICAL ZONE
REASSESSMENT
Completed 50 cc/kg IVD Sterofundin
No GI losses, abdominal pain improving, no SOB/chest pain

OE: weak looking, less tachypnoic, CRT< 2SEC, warm peripheries, good pulse volume
BP 144/78 PR 102 DXT 16.9
Lungs: clear Abd : soft, non distended

IX PH 7.1 HCO3 7.1 LAC 1.5 K4.4

Bedside scan A profile bilaterally, no pleural effusion, ECHO – good contractility
No dilated chambers, IVC collapsible > 50%
REVISED DIAGNOSIS
1)DKA SEC TO CAP AND MISSED MEDICATION
2) TRO IO

Plan
 For IVD Sterofundin 1L over 2 H
 Start IVD maintenance 5 pint Sterofundin over 24 H
 Continue IVI Insulin
 DXT hourly, if DXT < 15 to change to IVD D10% 125 cc/H
 Serum ketone per shift
 Trace AXR, if no dilated bowel to off RT
 Refer medical
INVESTIGATIONS

 Urea 11.6 Na 121 K 9.6 (lysed) Creat 68

 Mg 1.05 Ca 2.23 PO4 1.49
 ALT 37 ALP 116 AST 79 TB 6 ALB 37
 Amylase 83
 INR 0.8 PT 9.4 APTT 27
DISCUSSION
Pathophysiology

https://youtu.be/-B-RVybvffU?si=9cMy50ZF_IvekQgH
DIAGNOSTIC CRITERIA FOR DKA

All 3 criteria must be met

1. Capillary plasma glucose >11 mmol/L
2. Capillary ketones >3 mmol/L or urine ketones ≥2+
3. Venous pH <7.3 and/or bicarbonate <15 mmol/L
CLINICAL PARAMETERS FOR SEVERE DKA

1. Venous bicarbonate <5 mmol/L

2. Plasma ketones >6 mmol/L
3. Venous pH <7.1
4. Hypokalaemia on admission (<3.5 mmol/L)
5. GCS <12
6. Oxygen saturation <92% on air (via arterial blood gases [ABG])
7. Systolic BP <90 mmHg
8. Pulse >100 beats/minute
9. Anion gap >16 (Anion gap = [Na+ + K+ ] – [Cl- + HCO3 - ])*
ASSESSMENT

 History and physical examination

Look for precipitating causes: infection, missed therapy, non-adherence, acute coronary syndrome, cerebrovascular
accident, surgery and drugs (e.g. steroids).
 Investigations
 Capillary and venous plasma glucose
 Venous blood gas (pH, bicarbonate)
 Blood or urinary ketones - BUSE and creatinine
 FBC
 Urinalysis
 If indicated: blood cultures, CXR and ECG
PRINCIPLES OF MANAGEMENT

1. Correction of dehydration
2. Correction of electrolyte imbalance
3. Insulin therapy
4. Treatment of precipitating factor
5. Prevention of complications
AIMS OF TREATMENT

1. Rate of fall of ketones of at least 0.5 mmol/L/hr, OR

2. Bicarbonate rise of 3 mmol/L/hr, AND
3. Plasma glucose fall of at least 3 mmol/L/hr, AND
4. Maintain serum potassium within normal range.

 Precaution during treatment

Avoid over-correction of hyperglycaemia (within the first 12-24 hours of treatment, avoid lowering glucose to <14.0
mmol/L)
MONITORING

1. Hourly capillary plasma glucose until it reaches maintenance level of 8 mmol/L12 mmol/L,
then monitor 2-4 hourly.
2. Vital signs and input-output charting hourly
3. Venous HCO3 - and K+ at 60 minutes, 4 hours and 6-hourly thereafter
4. 6-hourly BUSE and blood/urine ketones
5. If ketones and glucose are not falling as expected, check if the insulin infusion pump is
working and connected, and the correct insulin residual volume is present.
6. If equipment is working but response to treatment inadequate, increase insulin infusion rate
by 1 U/hr increments hourly until targets are achieved.
RESOLUTION OF DKA

1. Continue IV insulin infusion until resolution of DKA

2. › pH >7.3
3. › Plasma ketone <0.6 mmol/L
TRANSITIONING FROM IV INSULIN TO SC BASAL BOLUS
INSULIN

 Patient should be eating and drinking, and back on normal insulin.

 Overlap the SC insulin with the insulin infusion for ½ hour (for insulin analogues) or 1 hour (for human insulin).
 Calculating a basal bolus regimen (4 times daily)
 Current practice is shifting away from estimating total daily dose (TDD) of SC insulin based on the last 12-24-hour-
insulin administered.
 Estimate total daily dose (TDD) of insulin by multiplying the patient’s weight (in kg) by 0.5 U-0.75 U.
 › Use 0.75 U/kg for those considered to be more insulin resistant e.g. obese and/or presence of acanthosis nigricans. ›
Give 50% of TDD at bedtime in the form of long acting insulin and divide remaining dose equally between pre-
breakfast, pre-lunch and pre-dinner meals.
 For patients already on insulin before admission, consider resuming previous insulin regimen and adjust dose as
needed.
 Monitor and adjust insulin doses accordingly
EUGLYCAEMIC KETOACIDOSIS

 Definition for euglycaemic ketoacidosis is plasma glucose level <11.0

mmol/L
 Treatment should follow standard DKA management protocol except
dehydration is corrected with 5% dextrose saline or 5% dextrose
 A high index of suspicion is required for its timely diagnosis because of
the absence of very high glucose levels as seen classically in patients with
DKA.
TAKE HOME MESSAGES

 Prompt recognition and institution of treatment are important to avoid complications.

 Severe DKA should be managed in a high dependency or intensive care unit.
 Patients must be educated on precipitating factors to avoid DKA or HHS.
 Mainstay of treatment includes restoration of hydration, insulin infusion, correction of
electrolytes imbalance and treatment of precipitating cause.
REFERENCE

 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF TYPE 2 DIABETES MELLITUS (6th Edition)

DECEMBER 2020 MOH/P/PAK/447.20(GU)-e

 Osmosis from Elsevier – You tube channel (Diabetes mellitus (type 1, type 2) & diabetic ketoacidosis (DKA)