Diabetic Ketoacidosis (Case 43)

Chapter 85 Diabetic Ketoacidosis (Case 43)



Meg A. Frizzola, DO




Case


A 10-year-old girl presents to the emergency department with abdominal pain, headache, and “confused and slurred” speech for the past 12 hours. Her parents report she has lost approximately 10 pounds in the past month and has seemed to have very frequent urination and insatiable thirst, drinking several liters of water a day.




Differential Diagnosis








Diabetic ketoacidosis (DKA) Hyperosmolar hyperglycemic nonketotic state (HHNK)


Speaking Intelligently


When I am presented with a patient with the constellation of symptoms described above, I strongly suspect DKA and work to both resuscitate the patient and achieve a diagnosis. Initial focus on the ABCs of airway, breathing, and circulation is appropriate, as well as obtaining an initial set of vital signs and attempting to place at least one large IV for eventual fluid resuscitation. Laboratory values are extremely important in diagnosis, so I immediately obtain a blood gas and a dextrostick as well as a urine specimen to determine the presence of glucose and/or ketones. Electrocardiogram (ECG) monitoring is important because of the electrolyte abnormalities. Patients with DKA can be assumed to have at least a 10% fluid deficit and will require volume resuscitation; however, cerebral edema is a real and serious complication, and judicious fluid use is warranted. It is best to start with 10 to 20 mL/kg of an isotonic solution, such as normal saline (0.9% sodium chloride). Although fluid resuscitation is crucial, insulin administration, typically in the form of a continuous infusion, is important to stop the ketosis and reverse the acidosis. Bicarbonate is generally not indicated to treat the acidosis. Finally, the level of obtundation/depressed consciousness is important to assess. Neuroimaging and appropriate management of cerebral edema with mannitol or 3% saline should be instituted if necessary (see Chapter 81, Raised Intracranial Pressure).



Patient Care



Clinical Thinking



• Support airway, breathing, and circulation.

• Is there evidence of neurologic impairment? Do I have to immediately treat cerebral edema?

• Are there other contributing factors, such as infection, stress, or missed insulin dose, that led the patient to develop DKA?

• What is the degree of dehydration of this patient?


History



• Consider contributing conditions, such as infection, missed dose of insulin, pregnancy, or stress that led to the development of DKA.

• Consider family history of type 1 diabetes or other autoimmune disorders.

• Ensure low likelihood of ingestion or starvation before arriving at diagnosis of DKA.

• Often history of vomiting, headaches, polyuria, and polydipsia with significant weight loss over brief period of time.


Physical Examination



• Vital signs: Expect to see tachycardia, sometimes with hypotension, elevated respiratory rate, afebrile (usually). Hypertension may be a warning sign of cerebral edema.

• General appearance: ill-appearing, malaise, obtundation or confusion.

• Head, ears, eyes, nose, and throat (HEENT) exam will reveal dry mucous membranes, acetone (fruity) breath.

• Kussmaul respirations may be noted.

• Check pupils and fundi for signs of cerebral edema and increased intracranial pressure (ICP).

• May have vague, diffuse abdominal pain.


Tests for Consideration



• Arterial blood gas levels: Crucial to obtain pH and bicarbonate level to determine degree and etiology of acidosis $156

• Electrolyte levels, blood urea nitrogen (BUN), and creatinine level: Important to monitor sodium, potassium, bicarbonate, chloride, magnesium, phosphorus, BUN, and creatinine level $68

• Complete blood count (CBC) with differential: Important if suspect infection $53

• Glucose level: Elevated above 200 mg/dL $29

• Hemoglobin A1C: Useful for determining degree of control of diabetes $25

• Urinalysis: Check for presence of ketones and glucose $110

• β-Human chorionic gonadotropin in adolescent female patients $25
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Related posts:

  1. The Special Needs Child
  2. Diarrhea (Case 6)
  3. Pediatric Poisonings (Case 54)
  4. Note Writing

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Diabetic Ketoacidosis (Case 43)

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