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Senior - E Med > 7 - DKA > Flashcards

7 - DKA Flashcards

1
Q

patient population for DKA?

A

Molsty DM 1

10-30% are new DM2

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2
Q

Pathophys of DKA?

A

Absence of insulin and excess counter-regulatory hormones result in

  • hyperglycemia,
  • osmotic diuresis,
  • preenteral azotemia
  • Worseing hyperglycemia
  • Ketone formation
  • Wide-anion-gap metabolic acidosis
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3
Q

What are counter-regulatory hormones?

A

Glucagon
Catecholamines
Cortisol
Growth hormone

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4
Q

Causes of DKA?

A

Often idiopathic but…

  • stopping insulin
  • infection
  • pregnancy
  • hyperthyroid/pheo/cushing
  • cocaine
  • meds (steroids, thiazides, antipsychotics)
  • heat injury
  • cerebrovascular accident
  • GI hemorrhage
  • myocardial infarction
  • PE
  • pancreatitis
  • maj trauma
  • surgery
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5
Q

Clinical manifestations of DKA are related to?

A

Hyperglycemia
Volume depletion
Acidosis

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6
Q

Symptoms of DKA?

A 
Polydipsia
Polyuria
Ketones in urine
Increased ventilation (acidosis)
Prostaglandin 
- N/V
- Abd pain 
Altered mental
Fruity breath
Hypothermia
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7
Q

What condition can be hard to distinguish from DKA?>

A

Pancreatitis

- both have abdominal pain and elevated serum amylase or lipase

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8
Q

Diagnostic criteria for DKA?

A 
Glucose >250
Anion gap >10
Bicarb <15
pH <7.3
Ketonuria
Ketonemia
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9
Q

Euglycemic ketoacidosis?

A

Glucose <300

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10
Q

DDX for DKA?

A

Alcoholic ketoacidosis
Starvation ketoacidosis
Renal failure
Lactic acidosis

Ingestion of

  • salicylate
  • ethylene glycol
  • methanol
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11
Q

Lab testing for DKA?

A 
Rapid bedside glucose 
Venous blood gas (VBG)
CMP
CBC
calculated anion gap (AG)
ABG
Ketones
Potassium
ECG
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12
Q

What effect does DKA have on potassium?

A

Low potassium from renal losses

Can be normal or High sometimes b/c

  • extracellular shift
  • increased intravascular osmolarity
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13
Q

ECG changes from DKA?

A

Hyperkalemia or hypokalemia

Also signs of ischemia
- b/c MI may precipitate DKA

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14
Q

If you suspect DKA at triage you should?

A

Aggressive fluid therapy should be initiated

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15
Q

Order of therapeutic priorities for DKA?

A 
Volume first and foremost
Then
Correction of K+
Then 
Insulin administration
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16
Q

Treatment of metabolic disturbances?

A

Corrected at approximate rate of occurrence
Or
Over 24-36hrs

Monitoring every 2hrs of electrolyes, vital signs, mental status, and volume

17
Q

Numeric volume goals of treatment?

A

Glucose <200mg/dL
Bicarbonate >/= 18mEq/L
Venous pH >7.3

18
Q

Most important factor in treating DKA?

Why?

A

IV fluid administration

Restores IV volume and tonicity
Perfuses vital organs
Improves GFR
Lowers serum glucose 
Lowers ketone levels
19
Q

What fluids do you treat DKA with?

A

NS initially
Once corrected then change to 0.45%NS

1st - 2 L in 2 hrs

2nd - 2L in 2-6hrs

When glucose is 250mg
- switch to 5% dextrose in 0.45% NS

20
Q

What is potentially the most life-threatening electrolyte derangement during treatment of DKA?

A

Rapid development of severe hypokalemia

21
Q

If initial serum potassium level is

> 3.3mEq/L
but
<5.2 mEq/L

you should?

A

Administer IV K+ at 20-30mEq/L/hr x 4 hrs

22
Q

What does K >5.2 reflect?

A

More profound acidemia and volume depletion or renal insufficiency

23
Q

Insulin administration for DKA?

A

After bolus NS

0.1-0.14 unit/kg/h (once hypokalemia is excluded)

Once glucose is 200mg/dL addd dextrose to IV
Reduce insulin to 0.02 to 0.05 unit/kg/h

24
Q

Continue insulin infusion until?

A

Glucose <200 and 2 of the following

Bicarb >15mEq/L
Venous pH >7.2
Normal calculated anion gap

25
Q

K+ >3.3 - < 5.2mEq/L

A

Give IV fluid
Give IV K
Give IV insulin

26
Q

K+ <3.3mEq/L

A

Give IV fluid
Give IV K
Hold insulin

27
Q

K >5.2mEq/L

A

Give IV fluids
Hold K+
Give Insulin

28
Q

Complications of acute DKA?

A

Loss of airway
Sepsis
MI
Hypovolemic shock

29
Q

Complications of DKA related to therapy?

A 
Hypokalemia
Hypophosphatemia
ARDS
Cerebral Edema
Hypoglycemia
30
Q

Complications of DKA late complications?

A

Recurrent anion gap metabolic acidosis
Non-anion gap metabolic acidosis
Vascular thrombosis
Mucormycosis

31
Q

Where do DKA pts get admitted to?

A

ICU if critical

General med/surg if:

  • anion gap <25
  • glucose < 600mg/dL
  • no comorbidities
32
Q

Leading cause of fetal loss?

A

DKA, fetal mortality rate of 30%

33
Q

Colonel: You write “born to kill” on your helmet, and you wear a peace button. What’s that supposed to be, some kind of sick joke?

A

Joker: No, sir.

Senior - E Med (8 decks)

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