Critical Cases - Severely agitated DKA patient!

CC = "whole body pain"



  • 23 yo male hx of IDDM presents via EMS with c/o "whole body pain"
  • Glucose per ALS >600 
  • Pt states hasn't taken insulin in several days
  • Pt unwilling to provide any further history, demanding pain medication before he will discuss history further



  • IDDM with hx of multiple admissions for DKA


Social History

  • 2.5 ppd smoker, no recreational drug use


Physical Exam

  • VS: T 97.6  HR 120   BP 137/72  RR 40  Pox: 100%
  • Acutely agitated, markedly tachypneic
  • Dry mucous membranes
  • Lungs clear, heart tachy no mrg
  • Abd soft NTND
  • Extremities warm and well perfused without edema

POC glucose: >600 mg/dL


  • Diabetic ketoacidosis
  • Sepsis
  • Overdose: specifically salicylate toxicity


  • Pt redirected to his stretcher and placed on 1:1 observation
  • IV access established and 2L LR bolus initiated
  • ECG: Sinus tachycardia, no peaked T waves or widened QRS concerning for hyperkalemia
  • Labs: CBC, Chem basic, VBG, serum ketones, UA
  • Insulin infusion 0.13 u/kg/hr ordered and brought to bedside: administration was held pending serum potassium level (insulin should not be administered if initial potassium is <3.3)


Case Progression

  • VBG showed: pH 7.02 pCO2 24 HCO3 8 (interpretation: primary metabolic acidosis with appropriate respiratory compensation)
  • Chem basic: Sodium 134 Potassium 5.2.  Cl 94  HCO3 7  BUN 27  Cr 1.41  Glucose 770 AG 33
  • Pt became increasingly agitated, removing IV lines and interfering with insulin infusion
  • Pt placed on dexmedetomidine 
  • Agitation failed to improve, repeat blood gas showed pH 6.80
  • Attempted sedation with midazolam and ultimately haloperidol, without improvement in agitation 


Intubation and Case Resolution

  • In lieu of worsening acidosis and agitation, decision made to intubate patient to allow for treatment to proceed
  • Attempted intubation with ketamine alone to preserve respiratory drive and prevent acute respiratory acidosis
  • Intubation failed due to jaw clenching, requiring admistration of rocuronium 
  • Pt intubated on first pass with video laryngoscopy
  • Placed on ventilation with TV 450 ml and RR 26 in an attempt to match patient's pre-intubation minute ventilation
  • AG closed over the next 12 hours on insulin infusion, and acidosis resolved


Take-away points

  • Patients with severe acidosis will often be acutely encephalopathic and combative, making provision of care difficult
  • Sedation of patients with severe metabolic is potentially dangerous, as many sedative agents decrease respirations and thus impede adequate respiratory compensation for metabolic acidosis
  • If patients require intubation, often an attempt at awake intubation i.e induction agent only, without paralysis, may help to prevent an acute respiratory acidosis from apnea
  • If patients require paralysis, the goals of intubation are: 1) to establish an endotracheal tube rapidly by using the most experienced operator 2)  to rapidly re-establish a patient's respiratory compensation by aiming for high minute ventilation (tidal volume X respiratory rate)