CC = "whole body pain"

HPI

• 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

PmHx

• 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

Ddx

• Diabetic ketoacidosis
• Sepsis
• Overdose: specifically salicylate toxicity

Workup/Management

• 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)