Dr. Ashraf Hussein Ismail E.R Consultant, PSH

DKA
By
Dr. Ashraf Hussein Ismail
E.R Consultant, PSH
Diagnostic Criteria:
- Blood glucose > 250 mg/dL
- Arterial pH <7.3
- Serum Bicarbonate < 18 mEq/L
- Anion Gap > 10
- Ketonuria and/or ketonemia
Case 1
HISTORY
A 14-year-old male is brought to the Emergency Department via ambulance
as he was found semiconscious with repeated vomiting. The mother stated
that he is diabetic but he was not compliant to his medication.
PHYSICAL EXAMINATION
Blood pressure: 101/72; heart rate: 123; respirations: 32; oral temperature:
34.8°C; pulse oximetry: 100% on room air.
He is thin 50 Kg ,responds to simple questions with moans, but is, in general,

responsive only to very loud or painful stimuli.
Head and neck are normal, except for his oropharynx, which demonstrates
very dry mucous membranes His lungs are clear. His respiratory pattern is
that of rapid and deep breathing (Kussmaul breathing).
Abdomen exam is negative.
No other pathological findings on PE.
COURSE IN THE EMERGENCY DEPARTMENT

An intravenous infusion of normal saline was established and hydration was
initiated at a rate of 200 cc/hr. A serum glucose determination (Accucheck) was
too high to read. A sample of the blood was sent to the lab for a definitive
determination of the serum glucose level.
A bolus of 10 units of regular insulin IV was given while waiting for the lab
results.
Lab results
ABG (pH of 6.92, CO2 of 9 and a bicarb of 2)
WBC (62,600) Hg (14.4 mg/dL) Hematocrit of 43.5%
Na =127, K = 5.2, Cl =87, CO2 of less than 5, BUN of 32, creatinine 1.5
and a blood sugar of 1,582. S. acetone was +ve
The patient was started on an infusion of regular insulin at 10 units per
hour.
Blood and urine cultures were sent to the lab.
Antibiotics were administrated.
His respiratory rate decreased. His vital signs stabilized. The level of
consciousness was increased and he could talk to us.
Fluids were adjusted to 160 cc/hr and the insulin infusion was decreased
to 5 units/hr.
Patient was then transferred to ICU after stabilizes in ER.
Case 2
34 year old man, brought to ED due to loss of consciousness. A known case of
diabetic and hypertension. Experienced vomiting and abdominal pain before
loss of consciousness.
Investigations: RBS (490 mg/dl), U&E, ABG (mild acidosis), osmolality, FBC,
and blood culture. urine test: ketones, CXR(pneumonia)
Management : IV access and start fluid(0.9% saline) replacement
immediately. plasma glucose: >20mmol/L so, given 6u soluble insulin as IV
Bolus; Then IV infusion @ 0.1 Units/Kg/hr (100 Units/100 mL NS)
Fluid replacement Give 1L of 0.9% saline stat. Then typically, 1L over the next
hour, 1L over 2 hour, 1L over 4 hour, then 1L over 6 hour. Use dextrose saline
or 5% dextrose when blood glucose is <15mmol/L.
 K replacement : if Serum potassium <3.0 add 40 mmol KCl to each liter
if Serum potassium 3 -4 add 30 mmol KCl to each liter
if Serum potassium 4-5 add 20 mmol KCl to each liter
Case 3
15 year old male patient with no significant PMH c/o easily fatigability,
poliuria, polidipsia, dry tongue and loss of wt.
Vital signs: B.P = 140/87 p = 114 temp = 36.7 RR= 21
Lab work shows:
RBS =562 mg/dl acetone in urine ++++ ABG (PH = 7)
U&E ( K =3.5) UA
ER course:
Fluid replacement Give 1L of 0.9% saline stat. Then typically, 1L over
the next hour, 1L over 2 hour, 1L over 4 hour, then 1L over 6 hour. Use
dextrose saline or 5% dextrose when blood glucose is <15mmol/L.
given 6u soluble insulin as IV Bolus; Then IV infusion @ 0.1
Units/Kg/hr (100 Units/100 mL NS)
 K replacement : if Serum potassium <3.0 add 40 mmol KCl to each liter
Patient diagnosed as 1st discovered DM &
DKA he was admitted under I.M with I.V
Zinnat 500mg /12h and he has improved
over the following 4 days and disharged on
medication.
Case 4
17 ylo female patient k/c of IDDM c/o dizziness, vomiting
She did not take her insulin doses for 2 days
Lab work: RBS = 435 mg/dl acetone +
ABG ( PH = 7.24 HCO3 = 11 Pco2 = 23 po2 = 91% U&E
UA
ER course:
Fluid replacement Give 1L of 0.9% saline stat. Then typically, 1L over
the next hour, 1L over 2 hour, 1L over 4 hour, then 1L over 6 hour. Use
dextrose saline or 5% dextrose when blood glucose is <15mmol/L.
given 6u soluble insulin as IV Bolus; Then IV infusion @ 0.1
Units/Kg/hr (100 Units/100 mL NS)
 K replacement : if Serum potassium <3.0 add 40 mmol KCl to
each liter
The patient was admitted and imroved in
the following 3 days and was discharged
Case 5
35 yo man had a 20 year history of well controlled type 1 DM, on tds
Novorapid + nocte Lantus. Never had an episode of DKA, some
hypos.
Presented to ED at midnight with a history of vomiting and polyuria
since 08:00. Had been trying to drink water and had taken a small
dose (12 iu) of Novorapid then his usual dose of Lantus (40 iu) just
prior to presenting.
On arrival – alert, oriented, ketotic breath. RR = 28/min, p = 120,
BP110/70, pale hands. Ongoing vomiting. Initial VBG: pH 7.30, pCO2
– 28, HCO3 – 15, BSL 32, Na- 133, K+ = 4.3, lactate – 4.2. Urinalysis
= large ketones
IV access and rehydration commenced – 1 L N/s stat, given 10 iu
Novorapid IV, then commenced on infusion @ 3 iu/hr (Lantus also on
board). After 30 mins the BSl had fallen to 24, another 1000 mls
commenced over 1 hour. Repeat ABG after this showed: pH 7.30,
pCO2 = 43, HCO3 – 19, lactate down to 2.0.
After this we slowed the IV fluids – he began
to pass urine – commenced IV n/saline +
KCl 20mmol @ 250ml/hr. Insulin infusion
continued, BSL now 17.1. By 05:00 his BSL
was down to 12, his urine still showed
moderate ketones. IV fuid changed to 5%
dextrose and the Insulin continued at 3 iu/hr.
By breakfast time he was hungry and we
gave him a feed and ceased the insulin
infusion – gave his usual dose of Novorapid.
He was disharged for OPD follow up.
Thank you

Dr. Ashraf Hussein Ismail E.R Consultant, PSH

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DKA

He is thin 50 Kg ,responds to simple questions with moans, but is, in general,

COURSE IN THE EMERGENCY DEPARTMENT

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