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Can Ketoacidosis Cause Chest Pains?

Diabetic Ketoacidosis: “sneaky” Triggers And Clinical Pearls

Diabetic Ketoacidosis: “sneaky” Triggers And Clinical Pearls

Authors: Catherine Reynolds, MD (EM Resident Physician, UT Houston), Kathryn Fisher, MD (EM Resident Physician, UT Houston), and Hilary Fairbrother, MD (EM Attending Physician, UT Houston) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit) Clinical Case #1: The patient is a 45-year-old male with history of type 2 DM and HTN who presents to the emergency department with diffuse abdominal pain, nausea, and vomiting for two days. The patient reports that he was recently started on Invokana (canagliflozin) about two weeks ago for his diabetes, and prior to that he was managing his sugars with diet and exercise alone. The patient has had difficulty keeping any food down over the last two days, but denies shortness of breath, chest pain, or fever. He reports his vomit is non-bilious and non-bloody. His initial finger stick is 84 mg/dL, and your intern states that he “knows that this is not DKA” as the serum glucose is normal. Vital signs showed RR 28, HR 110, BP 152/86, SpO2 98% on room air, T 98.4 F. Labs on presentation reveal a Na of 132 mmol/L, K of 5 mmol/L, Cl of 98 mmol/L, bicarbonate of 10 mmol/L, glucose of 84 mg/dL, and venous pH of 7.1. Venous lactate is within normal limits, and serum beta-hydroxybutyrate is positive. The patient is started on dextrose-containing fluids, an insulin drip, and admitted to the ICU for DKA. What was the cause of the patient’s euglycemic DKA? Clinical Case #2: The patient is a 62-year-old male with a history of DM, CAD, HTN, HLD, an NSTEMI, and 2 subsequent cardiac stents. He presents to the ED with diffuse abdominal pain, nausea, vomiting, and diarrhea for two days. The patient is on Humalog and Lantus but he hasn’t taken the medications over the last two days because he hasn’t been eating. He denies s Continue reading >>

Multiple Intestinal Intussusceptions As A Complication Of Severe Hyperglycemia In A Patient With Diabetic Ketoacidosis

Multiple Intestinal Intussusceptions As A Complication Of Severe Hyperglycemia In A Patient With Diabetic Ketoacidosis

Volume 2012 |Article ID 526041 | 4 pages | Multiple Intestinal Intussusceptions as a Complication of Severe Hyperglycemia in a Patient with Diabetic Ketoacidosis 1Department of Medicine, Medical Education, Mount Carmel Health, 793 West State Street, Columbus, OH 43222, USA 2Division of Critical Care Medicine, Mount Carmel Health, Columbus, OH 43222, USA 3Department of Medicine, Nassau University Medical Center, East Meadow, NY 11554, USA Intussusception in adults is a rare phenomenon, occurring in approximately 1 in 30,000 hospital admissions annually. When it does occur, the majority of cases involve an organic lesion serving as a lead point for intussusception, such as tumors or postoperative adhesions. In a small percentage of cases, a lead point is not found, and intussusception is thought to be idiopathic or secondary to a disease process contributing to dysrhythmic peristalsis of the gastrointestinal tract. A few cases of functional intussusception have been reported as being secondary to severe hyperglycemia and metabolic derangements, including metabolic acidosis and hyperkalemia, by causing impaired gastrointestinal motility. We present a case of a 23-year-old Caucasian male who presented with severe hyperglycemia and diabetic ketoacidosis. Imaging of the abdomen revealed three intussusceptions involving the small intestine, which were easily reduced manually during exploratory laparotomy. Intussusception is a phenomenon more common in the pediatric population and is usually idiopathic or secondary to a viral etiology. Intussusception in adults is infrequent and typically occurs in the setting of an organic lesion serving as a lead point for intestinal telescoping, such as a tumor or adhesions from previous abdominal surgery [ 1 ]. Functional intussusception, Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

The Facts Diabetic ketoacidosis (DKA) is a condition that may occur in people who have diabetes, most often in those who have type 1 (insulin-dependent) diabetes. It involves the buildup of toxic substances called ketones that make the blood too acidic. High ketone levels can be readily managed, but if they aren't detected and treated in time, a person can eventually slip into a fatal coma. DKA can occur in people who are newly diagnosed with type 1 diabetes and have had ketones building up in their blood prior to the start of treatment. It can also occur in people already diagnosed with type 1 diabetes that have missed an insulin dose, have an infection, or have suffered a traumatic event or injury. Although much less common, DKA can occasionally occur in people with type 2 diabetes under extreme physiologic stress. Causes With type 1 diabetes, the pancreas is unable to make the hormone insulin, which the body's cells need in order to take in glucose from the blood. In the case of type 2 diabetes, the pancreas is unable to make sufficient amounts of insulin in order to take in glucose from the blood. Glucose, a simple sugar we get from the foods we eat, is necessary for making the energy our cells need to function. People with diabetes can't get glucose into their cells, so their bodies look for alternative energy sources. Meanwhile, glucose builds up in the bloodstream, and by the time DKA occurs, blood glucose levels are often greater than 22 mmol/L (400 mg/dL) while insulin levels are very low. Since glucose isn't available for cells to use, fat from fat cells is broken down for energy instead, releasing ketones. Ketones accumulate in the blood, causing it to become more acidic. As a result, many of the enzymes that control the body's metabolic processes aren't able Continue reading >>

Diabetic Ketoacidosis Clinical Presentation

Diabetic Ketoacidosis Clinical Presentation

History Insidious increased thirst (ie, polydipsia) and urination (ie, polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA). Malaise, generalized weakness, and fatigability also can present as symptoms of DKA. Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia. A history of rapid weight loss is a symptom in patients who are newly diagnosed with type 1 diabetes. Patients may present with a history of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons. Decreased perspiration is another possible symptom of DKA. Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe. Among the symptoms of DKA associated with possible intercurrent infection are fever, dysuria, coughing, malaise, chills, chest pain, shortness of breath, and arthralgia. Acute chest pain or palpitation may occur in association with myocardial infarction. Painless infarction is not uncommon in patients with diabetes and should always be suspected in elderly patients. A study by Crossen et al indicated that in children with type 1 diabetes, those who have had a recent emergency department visit and have undergone a long period without visiting an endocrinologist are more likely to develop DKA. The study included 5263 pediatric patients with type 1 diabetes. [15] Continue reading >>

Is It Really A Health Emergency Or Is There A Much Simpler Explanation?

Is It Really A Health Emergency Or Is There A Much Simpler Explanation?

Is it really a health emergency or is there a much simpler explanation? Use our traffic light guide to assess whether youre actually seriously ill - or just need an early night Discomfort: But stomach pain can have many causes (Image: Getty Images) Sign up to FREE daily email alerts from Mirror - daily news We will use your email address only for sending you newsletters. Please see our Privacy Notice for details of your data protection rights Thank you for subscribingWe have more newsletters Show me See our privacy notice Is it really an emergency.. or do you just need an early night? This month figures have revealed that more than half of A&E visits were for non-emergencies so how do you know when you really need medical attention or if its something a lot less serious? How do you know if youre a hypochondriac or just health-aware? How do you tell if your stomach pain is life-threatening or down to that huge take-away? How can you tell if that throbbing is just a headache and not a brain tumour? We asked the experts for a traffic-light guide to assessing your health risk. A 'green' signal means theres probably nothing to be concerned about and an early night could help; an 'amber' signal suggests you should get checked out by your GP. And a 'red' signal indicates medical attention should be sought immediately. Phone 111 for advice; book an emergency GP appointment or, if necessary, go straight to A&E or dial 999 for an ambulance. Green : IBS (Irritable Bowel Syndrome) is the commonest cause of abdominal pain, explains Dr Adam Harris, Consultant Gastroenterologist at The Tunbridge Wells Hospital. Pain tends to be gradual and moves around, or comes and goes and varies in intensity, but doesnt usually disturb sleep. Try keeping a food diary to eliminate triggers, drink p Continue reading >>

My First Encounter With Diabetic Ketoacidosis

My First Encounter With Diabetic Ketoacidosis

I saw a post last night that a friend shared about a young girl with type 1 diabetes that had passed away. Her pump site apparently kinked and she went into DKA and then had brain damage, so her parents had to make the heartwrenching decision to remove her from life support. This led to a conversation with a couple of friends as I recounted my story of my first time in DKA. It will be forever ingrained in my head, so I thought I’d share it here as well. I was in college 3+ hours away from home. And about 4 1/2 years post dx. I was visiting my boyfriend’s house and started feeling really sick. Started vomiting. To the point of not being able to get up off of the bathroom floor. I called the campus nurse and she told me to drink some Diet Sprite. Couldn’t hold it down. Water? Couldn’t hold it down. Anything I put in, came right back up. This is not a good combination for anyone, but especially for a diabetic. At the time I had no idea how serious this was, but I was about to find out. After several hours of this cycle… my boyfriend needed to go to work but didn’t want to leave me alone. My mom was coincidentally going to be visiting me that weekend so he called the hotel to leave a message for her, not expecting her for another hour or so (this part gives me chills.) When the hotel front desk answered and he asked to leave a message for her, the receptionist said, “Oh, she is standing right here checking in.” She had gotten on the road earlier than expected. He told her I was very sick and he thought she should come stay with me, because I was too sick to drive back to my dorm. She immediately heads over there (a 20-min drive that maybe took her 10 min) and saw it was bad. I was soo soo incredibly sick. She said I needed to go to the ER, but I couldn’t w Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus.[1] Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and occasionally loss of consciousness.[1] A person's breath may develop a specific smell.[1] Onset of symptoms is usually rapid.[1] In some cases people may not realize they previously had diabetes.[1] DKA happens most often in those with type 1 diabetes, but can also occur in those with other types of diabetes under certain circumstances.[1] Triggers may include infection, not taking insulin correctly, stroke, and certain medications such as steroids.[1] DKA results from a shortage of insulin; in response the body switches to burning fatty acids which produces acidic ketone bodies.[3] DKA is typically diagnosed when testing finds high blood sugar, low blood pH, and ketoacids in either the blood or urine.[1] The primary treatment of DKA is with intravenous fluids and insulin.[1] Depending on the severity, insulin may be given intravenously or by injection under the skin.[3] Usually potassium is also needed to prevent the development of low blood potassium.[1] Throughout treatment blood sugar and potassium levels should be regularly checked.[1] Antibiotics may be required in those with an underlying infection.[6] In those with severely low blood pH, sodium bicarbonate may be given; however, its use is of unclear benefit and typically not recommended.[1][6] Rates of DKA vary around the world.[5] In the United Kingdom, about 4% of people with type 1 diabetes develop DKA each year, while in Malaysia the condition affects about 25% a year.[1][5] DKA was first described in 1886 and, until the introduction of insulin therapy in the 1920s, it was almost univ Continue reading >>

How Diabetes Can Mask The Symptoms Of A Heart Attack

How Diabetes Can Mask The Symptoms Of A Heart Attack

Weird, whispering symptoms are easy to overlook; how to prevent and recognize this risk for people with diabetes. In a new study of more than 9,000 people, silent heart attacks—with warning signs so quiet or so unusual that people didn’t seek medical help—were nearly as common as classic heart attacks with well-known symptoms like crushing chest pain. And they were almost as lethal in the long run, tripling the odds of dying during the 9-year study compared to people who didn’t have a heart attack of any kind. It’s a wake-up call for anyone at risk for heart disease, but heart experts say people with type 1 and type 2 diabetes should pay particular attention. “People with diabetes are at higher risk for silent heart attacks for several reasons,” says Om P. Ganda, M.D., medical director of the Lipid Clinic at the Joslin Diabetes Center in Boston and an associate clinical professor of medicine at Harvard Medical School. “High blood sugar can lead to autonomic nerve damage that reduces the ability to feel pain, including heart-attack pain. Your only symptom might be shortness of breath. And people with diabetes are already at two to three time’s higher risk for heart disease than people without diabetes, which also increases the chances for a silent heart attack.” In a 2013 British study of 5,102 people with type 2, heart tests showed that 16%— about one in six—had likely had silent heart attacks. People with type 1 diabetes may also be at higher-than-average risk, Dr. Ganda says, due to nerve damage and overall heart-disease risk. Lead researcher Elsayed Z. Soliman, M.D., MSc., M.S., director of the epidemiological cardiology research center at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, says silent heart attacks are dangerou Continue reading >>

Complications Of Type 1 Diabetes

Complications Of Type 1 Diabetes

DISCLAIMER: This Health Library is for educational purposes only and does not necessarily reflect the services provided by this practice/facility. Health problems can happen when blood glucose levels are out of the normal range. Having regular exams and tests can help find problems early and treat them. These problems can happen in a short time: These problems can happen after a longer time: Diabetic diseases of the eyes, kidneys, and nerves Hypoglycemia is low blood sugar. It can be caused by: Taking too much insulin for the amount of food that was eaten Taking too much insulin to treat "fasting" blood sugar Skipping a meal or eating a smaller meal without lowering the insulin dose Exercising harder or longer than normal without lowering the insulin dose Hyperglycemia is high blood sugar. It happens when a person does not have enough insulin to remove the glucose in the body. It can be caused by: Taking too little insulin for the food that was eaten Eating a larger meal without adjusting the insulin dose Exercising more or less than planned without adjusting the insulin dose Stress from being sick or life events (insulin may need to be adjusted) People with type 1 diabetes can get ketoacidosis . Sugar cannot get into cells to make energy when the body is not getting enough insulin. When this happens, the body starts breaking down stored fat for energy. The by-products of fat breakdown are ketone bodies. These are acids that build up in the blood that can cause ketoacidosis. It is caused by the same reasons as hyperglycemia. It may also be caused by taking too little insulin when sick with infection. Diabetic Diseases of the Eyes, Kidneys, and Nerves Diabetic retinopathy can happen when high blood sugar and blood pressure harm tiny blood vessels in the retina of the ey Continue reading >>

Metformin

Metformin

Metformin may rarely cause a serious, life-threatening condition called lactic acidosis. Tell your doctor if you have kidney disease. Your doctor will probably tell you not to take metformin. Also, tell your doctor if you are over 65 years old and if you have ever had a heart attack; stroke; diabetic ketoacidosis (blood sugar that is high enough to cause severe symptoms and requires emergency medical treatment); a coma; or heart or liver disease. Taking certain other medications with metformin may increase the risk of lactic acidosis. Tell your doctor if you are taking acetazolamide (Diamox), dichlorphenamide (Keveyis), methazolamide, topiramate (Topamax, in Qsymia), or zonisamide (Zonegran). Tell your doctor if you have recently had any of the following conditions, or if you develop them during treatment: serious infection; severe diarrhea, vomiting, or fever; or if you drink much less fluid than usual for any reason. You may have to stop taking metformin until you recover. If you are having surgery, including dental surgery, or any major medical procedure, tell the doctor that you are taking metformin. Also, tell your doctor if you plan to have any x-ray procedure in which dye is injected, especially if you drink or have ever drunk large amounts of alcohol or have or have had liver disease or heart failure. You may need to stop taking metformin before the procedure and wait 48 hours to restart treatment. Your doctor will tell you exactly when you should stop taking metformin and when you should start taking it again. If you experience any of the following symptoms, stop taking metformin and call your doctor immediately: extreme tiredness, weakness, or discomfort; nausea; vomiting; stomach pain; decreased appetite; deep and rapid breathing or shortness of breath; dizzi Continue reading >>

Can Diabetes Cause Fatigue, Body Ache?

Can Diabetes Cause Fatigue, Body Ache?

Every weekday, a CNNHealth expert doctor answers a viewer question. On Wednesdays, it's Dr. Otis Brawley, chief medical officer at the American Cancer Society. Asked by Mike from Tennessee Can diabetes be a (possible) cause of fatigue, leg and lower back aches? I have had bursts of energy for 10 to 15 minutes, but then need to sit for about 10 minutes, and I'm ready to go full steam again. PLEASE, Thank You, Mike Expert answer Dear Mike: Thanks for an important question, as a lot of people with diabetes complain of these symptoms. The answer is that diabetes itself probably is not the cause of your fatigue, lower back and leg aches. The things that cause type 2 diabetes (also called adult onset diabetes), such as a weight problem and lack of exercise, are commonly the cause these symptoms. Fatigue incorporates three components: 1. The inability to initiate activity. 2. Reduced ability to maintain activity. 3. Difficulty with concentration and memory. Fatigue should be distinguished from sleepiness, shortness of breath on exertion and muscle weakness, although these can also be associated with fatigue. Fatigue lasting six months or more is referred to as chronic fatigue. Chronic fatigue is not necessarily the entity known as chronic fatigue syndrome, which is a diagnosis after exclusion of all other causes. Fatigue in anyone should be evaluated by a health care provider to exclude all possible causes and to get counseling on how to treat it. Other medical causes of fatigue are the side effect of drugs, thyroid dysfunction, high calcium levels, rheumatologic illnesses, adrenal, kidney or liver problems. Some infections such as tuberculosis or hepatitis can cause fatigue, and indeed, fatigue can be their only symptom. Depression is also a major cause of fatigue. While unus Continue reading >>

Diabetes Mellitus Type 2 In Adults

Diabetes Mellitus Type 2 In Adults

What is it? Diabetes (di-uh-BE-tez) is also called diabetes mellitus (MEL-i-tus). There are three main types of diabetes. You have type 2 diabetes. It may be called non-insulin dependent or adult onset diabetes. With type 2 diabetes, your body has trouble using insulin. Your body may also not make enough insulin. If there is not enough insulin or if it is not working right, sugar will build up in your blood. Type 2 diabetes is more common in overweight people who are older than 40 years and are not active. Type 2 diabetes is also being found more often in children who are overweight. There is no cure for diabetes but you can have a long and active life if your diabetes is controlled. How did I get type 2 diabetes? Insulin (IN-sul-in) is a hormone (a special body chemical) made by your pancreas (PAN-kree-us). The pancreas is an organ that lies behind the stomach. Much of the food you eat is turned into sugar in your stomach. This sugar goes into your blood and travels to the cells of your body to be used for energy. Insulin acts as a "key" to help sugar enter the cells. If there is not enough insulin or if it is not working right, sugar will build up in your blood. With type 2 diabetes, you may have better control of your diabetes with the right diet and exercise. You may also need to take oral medicine (pills) to help your body make more insulin or to use insulin better. You may also need insulin shots. No one knows for sure what causes type 2 diabetes. Type 2 diabetes runs in families. You are more likely to get it if someone else in your family has type 2 diabetes. You are also more likely to get type 2 diabetes if you are overweight. Being overweight makes it harder for your body to use the insulin it makes. This is called insulin resistance. In insulin resistance, y Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Topic Overview Diabetic ketoacidosis (DKA) is a life-threatening condition that develops when cells in the body are unable to get the sugar (glucose) they need for energy because there is not enough insulin. When the sugar cannot get into the cells, it stays in the blood. The kidneys filter some of the sugar from the blood and remove it from the body through urine. Because the cells cannot receive sugar for energy, the body begins to break down fat and muscle for energy. When this happens, ketones, or fatty acids, are produced and enter the bloodstream, causing the chemical imbalance (metabolic acidosis) called diabetic ketoacidosis. What causes DKA? Ketoacidosis can be caused by not getting enough insulin, having a severe infection or other illness, becoming severely dehydrated, or some combination of these things. It can occur in people who have little or no insulin in their bodies (mostly people with type 1 diabetes but it can happen with type 2 diabetes, especially children) when their blood sugar levels are high. What are the symptoms? Your blood sugar may be quite high before you notice symptoms, which include: Flushed, hot, dry skin. Blurred vision. Feeling thirsty and urinating a lot. Drowsiness or difficulty waking up. Young children may lack interest in their normal activities. Rapid, deep breathing. A strong, fruity breath odour. Loss of appetite, belly pain, and vomiting. Confusion. How is DKA diagnosed? Laboratory tests, including blood and urine tests, are used to confirm a diagnosis of diabetic ketoacidosis. Tests for ketones are available for home use. Keep some test strips nearby in case your blood sugar level becomes high. How is it treated? When ketoacidosis is severe, it must be treated in the hospital, often in an intensive care unit. Treatment invo Continue reading >>

Alcoholic Ketoacidosis

Alcoholic Ketoacidosis

Alcoholic ketoacidosis is a metabolic complication of alcohol use and starvation characterized by hyperketonemia and anion gap metabolic acidosis without significant hyperglycemia. Alcoholic ketoacidosis causes nausea, vomiting, and abdominal pain. Diagnosis is by history and findings of ketoacidosis without hyperglycemia. Treatment is IV saline solution and dextrose infusion. Alcoholic ketoacidosis is attributed to the combined effects of alcohol and starvation on glucose metabolism. Alcohol diminishes hepatic gluconeogenesis and leads to decreased insulin secretion, increased lipolysis, impaired fatty acid oxidation, and subsequent ketogenesis, causing an elevated anion gap metabolic acidosis. Counter-regulatory hormones are increased and may further inhibit insulin secretion. Plasma glucose levels are usually low or normal, but mild hyperglycemia sometimes occurs. Diagnosis requires a high index of suspicion; similar symptoms in an alcoholic patient may result from acute pancreatitis, methanol or ethylene glycol poisoning, or diabetic ketoacidosis (DKA). In patients suspected of having alcoholic ketoacidosis, serum electrolytes (including magnesium), BUN and creatinine, glucose, ketones, amylase, lipase, and plasma osmolality should be measured. Urine should be tested for ketones. Patients who appear significantly ill and those with positive ketones should have arterial blood gas and serum lactate measurement. The absence of hyperglycemia makes DKA improbable. Those with mild hyperglycemia may have underlying diabetes mellitus, which may be recognized by elevated levels of glycosylated Hb (HbA1c). Typical laboratory findings include a high anion gap metabolic acidosis, ketonemia, and low levels of potassium, magnesium, and phosphorus. Detection of acidosis may be com Continue reading >>

Infection As A Trigger Of Diabetic Ketoacidosis In Intensive Care—unit Patients

Infection As A Trigger Of Diabetic Ketoacidosis In Intensive Care—unit Patients

Together with hyperglycemic coma, diabetic ketoacidosis (DKA) is the most severe acute metabolic complication of diabetes mellitus [ 1 ]. Defined by the triad hyperglycemia, acidosis, and ketonuria, DKA can be inaugural or complicate known diabetes [ 2 ]. Although DKA is evidence of poor metabolic control and usually indicates an absolute or relative imbalance between the patient's requirements and the treatment, DKA-related mortality is low among patients who receive standardized treatment, which includes administration of insulin, correction of hydroelectrolytic disorders, and management of the triggering factor (which is often cessation of insulin therapy, an infection, or a myocardial infarction) [ 3–8 ]. Although there is no proof that diabetics are more susceptible to infection, they seem to have more difficulty handling infection once it occurs [ 9 , 10 ]. Indeed, several aspects of immunity are altered in diabetic patients: polymorphonuclear leukocyte function is depressed, particularly when acidosis is present, and leukocyte adherence, chemotaxis, phagocytosis, and bactericidal activity may also be impaired [ 11–15 ]. Joshi et al. [ 10 ] reported recently on the lack of clinical evidence that diabetics are more susceptible to infection than nondiabetic patients. Nevertheless, infection is a well-recognized trigger of DKA. Earlier studies have investigated the prevalence of infection as a trigger of DKA and the impact of antimicrobial treatment [ 2 , 15–18 ]. However, none of these studies were of intensive care unit (ICU) patients only. Furthermore, most were descriptive, included small numbers of patients, used univariate analysis only, and did not designate infection as the sole outcome variable of interest. Efforts to identify correlates of infection h Continue reading >>

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