Critical Cases - Severely agitated DKA patient!
Tue, 07/13/2021 - 5:21am
Editor:
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)