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Dka Myocardial Infarction

Myocardial Injury With Biomarker Elevation In Diabetic Ketoacidosis

Myocardial Injury With Biomarker Elevation In Diabetic Ketoacidosis

Abstract We report of two patients with severe ketoacidosis, minute elevations of myocardial biomarkers (troponin T and CK-MB) and initial ECG changes compatible with myocardial infarction (MI). All successive investigations, including coronary arteriography, were normal, and the patients recovered fully without further evidence of ischemic heart disease. We suggest that acidosis and very high levels of free fatty acids could cause membrane instability and biomarker leakage. Regardless of the pathogenesis, these two case stories suggest that nonspecific myocardial injury may occur in severe diabetic ketoacidosis and that the presence of minute biomarker elevation and ECG changes does not necessarily signify MI. 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 >>

“pseudoinfarction” Pattern Due To Hyperkalemia

“pseudoinfarction” Pattern Due To Hyperkalemia

A 38-year-old man presented to the emergency department with nausea, vomiting, and epigastric pain. The patient had type 1 diabetes mellitus and was being treated with insulin. He was also taking lisinopril for the treatment of hypertension. The initial electrocardiogram (Panel A) revealed sinus tachycardia and ST-segment elevation in leads V1 to V3 — findings highly suggestive of acute anteroseptal myocardial infarction. Peaked T waves were noted in leads II, III, aVF, and V3 to V6. The serum glucose concentration was 839 mg per deciliter (46.6 mmol per liter), the arterial blood pH was 7.21, and the serum potassium concentration was 7.9 mmol per liter. The diagnosis of diabetic ketoacidosis was made. When the electrocardiogram was repeated several hours later, after the potassium concentration was lowered to 5.1 mmol per liter with treatment (Panel B [lead V5 is not placed]), the ST-segment elevation disappeared completely, as did the peaked T waves. This case is an example of hyperkalemia causing a “pseudoinfarction” pattern. The clue to the correct diagnosis is the T wave in V4, which is tall, narrow, and pointed, with a short QT interval. The tall T waves that are characteristic of hyperacute ischemic changes tend to be associated with a long QT interval, and the T waves are broad rather than narrow and pointed. Kyuhyun Wang, M.D. Hennepin County Medical Center, Minneapolis, MN 55415 Continue reading >>

Distinctive Characteristics And Specific Management Of Diabetic Ketoacidosis In Patients With Acute Myocardial Infarction, Stroke And Renal Failure

Distinctive Characteristics And Specific Management Of Diabetic Ketoacidosis In Patients With Acute Myocardial Infarction, Stroke And Renal Failure

1. Introduction Diabetic ketoacidosis (DKA) is considered a predominantly acute type 1 diabetic complication, although it may occur in type 2 diabetes as well, particularly in patients who already have a decreased insulin secretion capacity. Stress –induced burst in catecholamine and ACTH secretion in acute myocardial infarction (AMI) promotes release of free fatty acids and their hepatic and muscular tissue utilization. The impairment in insulin-mediated intracellular glucose influx owing to the absent or insufficient pancreatic insulin secretion is the prerequisite for the occurrence of diabetic ketoacidosis. The results of the analysis of acid – base disturbances from our previous study [26] performed in the intensive-care unit in diabetics and non-diabetics suffering acute myocardial infarction are shown in Fig. 1. Cardiovascular accidents have a marked place among the possible causes of diabetic ketoacidosis. Cardiovascular morbidity influences the severity and duration of diabetic ketoacidosis and limits the first and most important step in its treatment- the fluid resuscitation. The resulting hyperosmolarity of body fluids precipitates a pro-thrombotic state, thus aggravating prognosis in patients with myocardial infarction. The clinical features of hyperglycemic/hyperosmolar state and diabetic ketoacidosis may overlap and are observed simultaneously (overlap cases) [44]. Acid-base disturbances in diabetics and non-diabetics suffering acute myocardial infarction: Almost one-third of diabetic patients with acute myocardial infarction had un-compensated metabolic acidosis defined as pH< 35, HCO3- < 22mmol/L. Although acidosis was mild in most of the cases at least third of these patients had criteria for true diabetic ketoacidosis (pH<30, HCO3- <15mmol/L). Addi Continue reading >>

Ecg Review: Dka And Acute Mi?

Ecg Review: Dka And Acute Mi?

ECG Review: DKA and Acute MI? Figure. 12-lead ECG obtained from a 32-year-old man who presented in DKA. Clinical Scenario: The ECG in the Figure was obtained from a previously healthy 32-year-old African American male who presented in coma from diabetic ketoacidosis (DKA). Cardiovascular exam was unremarkable. In addition to treating this patient’s DKA, should he also be considered a potential candidate for thrombolytic therapy? Interpretation: The ECG in the Figure shows normal sinus rhythm at a rate of about 60/minute. The PR interval is at the upper range of normal (= 0.21 second). The QRS and QT intervals are normal. The mean QRS axis is +60°. In view of the patient’s age, there is no evidence of chamber enlargement. Perhaps the most remarkable finding on this tracing is the presence of diffuse ST segment elevation. This finding is present in virtually all leads except III, aVR, and V1. It is most marked in lead V5, where ST segment elevation attains at least 3 mm. Despite the presence of diffuse ST elevation, it is highly unlikely that this pattern represents acute infarction. ST segment morphology is clearly upsloping (upward concavity), with marked notching of the J point in multiple leads (especially II, V4, V5, V6). The ST segment appearance that is characteristic of acute infarction is more typically coved (downward convexity) and is usually localized to 1 or 2 specific lead areas, rather than being as generalized as it is here. Marked acute ST segment elevation indicative of acute infarction is also commonly associated with reciprocal ST segment depression, which is not seen here. Although Q waves are present in the inferolateral leads, they are quite small and narrow. This is much more consistent with normal septal q waves rather than acute evolving inf Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Patient professional reference Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Pre-diabetes (Impaired Glucose Tolerance) article more useful, or one of our other health articles. See also the separate Childhood Ketoacidosis article. Diabetic ketoacidosis (DKA) is a medical emergency with a significant morbidity and mortality. It should be diagnosed promptly and managed intensively. DKA is characterised by hyperglycaemia, acidosis and ketonaemia:[1] Ketonaemia (3 mmol/L and over), or significant ketonuria (more than 2+ on standard urine sticks). Blood glucose over 11 mmol/L or known diabetes mellitus (the degree of hyperglycaemia is not a reliable indicator of DKA and the blood glucose may rarely be normal or only slightly elevated in DKA). Bicarbonate below 15 mmol/L and/or venous pH less than 7.3. However, hyperglycaemia may not always be present and low blood ketone levels (<3 mmol/L) do not always exclude DKA.[2] Epidemiology DKA is normally seen in people with type 1 diabetes. Data from the UK National Diabetes Audit show a crude one-year incidence of 3.6% among people with type 1 diabetes. In the UK nearly 4% of people with type 1 diabetes experience DKA each year. About 6% of cases of DKA occur in adults newly presenting with type 1 diabetes. About 8% of episodes occur in hospital patients who did not primarily present with DKA.[2] However, DKA may also occur in people with type 2 diabetes, although people with type 2 diabetes are much more likely to have a hyperosmolar hyperglycaemic state. Ketosis-prone type 2 diabetes tends to be more common in older, overweight, non-white people with type 2 diabetes, and DKA may be their Continue reading >>

Diabetes: Preventing Complications

Diabetes: Preventing Complications

Diabetes complications can be divided into two types: acute (sudden) and chronic (long-term). This article discusses these complications and strategies to prevent the complications from occurring in the first place. Acute complications Diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS) Acute complications of diabetes can occur at any time in the course of the disease. Chronic complications Cardiovascular: Heart disease, peripheral vascular disease, stroke Eye: Diabetic retinopathy, cataracts, glaucoma Nerve damage: Neuropathy Kidney damage: Nephropathy Chronic complications are responsible for most illness and death associated with diabetes. Chronic complications usually appear after several years of elevated blood sugars (hyperglycemia). Since patients with Type 2 diabetes may have elevated blood sugars for several years before being diagnosed, these patients may have signs of complications at the time of diagnosis. Basic principles of prevention of diabetes complications: Take your medications (pills and/or insulin) as prescribed by your doctor. Monitor your blood sugars closely. Follow a sensible diet. Do not skip meals. Exercise regularly. See your doctor regularly to monitor for complications. Results from untreated hyperglycemia. Blood sugars typically range from 300 to 600. Occurs mostly in patients with Type 1 diabetes (uncommon in Type 2). Occurs due to a lack of insulin. Body breaks down its own fat for energy, and ketones appear in the urine and blood. Develops over several hours. Can cause coma and even death. Typically requires hospitalization. Nausea, vomiting Abdominal pain Drowsiness, lethargy (fatigue) Deep, rapid breathing Increased thirst Fruity-smelling breath Dehydration Inadequate insulin administration (not getting Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic Ketoacidosis is a topic covered in the Washington Manual of Medical Therapeutics. The Washington Manual of Medical Therapeutics helps you diagnose and treat hundreds of medical conditions. Consult clinical recommendations from a resource that has been trusted on the wards for 50+ years. Explore these free sample topics: -- The first section of this topic is shown below -- DKA, a potentially fatal complication of diabetes, occurs in up to 5% of patients with T1DM annually and can occur in insulin-deficient patients with T2DM. DKA is a catabolic condition that results from severe insulin deficiency, often in association with stress and activation of counter-regulatory hormones (e.g., catecholamines, glucagon). Precipitating factors for DKA include inadvertent or deliberate interruption of insulin therapy, sepsis, trauma, myocardial infarction (MI), and pregnancy. DKA may be the first presentation of T1DM and, rarely, T2DM. DKA can be prevented in many cases, and its occurrence suggests a breakdown in education, communication, and problem solving. Therefore, diabetes education should be reinforced at every opportunity, with special emphasis on (a) self-management skills during sick days; (b) the body’s need for more, rather than less, insulin during such illnesses; (c) testing of blood or urine for ketones; and (d) procedures for obtaining timely and preventive medical advice. -- To view the remaining sections of this topic, please sign in or purchase a subscription -- Continue reading >>

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 >>

Cardiovascular Complications Of Ketoacidosis

Cardiovascular Complications Of Ketoacidosis

US Pharm. 2016;41(2):39-42. ABSTRACT: Ketoacidosis is a serious medical emergency requiring hospitalization. It is most commonly associated with diabetes and alcoholism, but each type is treated differently. Some treatments for ketoacidosis, such as insulin and potassium, are considered high-alert medications, and others could result in electrolyte imbalances. Several cardiovascular complications are associated with ketoacidosis as a result of electrolyte imbalances, including arrhythmias, ECG changes, ventricular tachycardia, and cardiac arrest, which can be prevented with appropriate initial treatment. Acute myocardial infarction can predispose patients with diabetes to ketoacidosis and worsen their cardiovascular outcomes. Cardiopulmonary complications such as pulmonary edema and respiratory failure have also been seen with ketoacidosis. Overall, the mortality rate of ketoacidosis is low with proper and urgent medical treatment. Hospital pharmacists can help ensure standardization and improve the safety of pharmacotherapy for ketoacidosis. In the outpatient setting, pharmacists can educate patients on prevention of ketoacidosis and when to seek medical attention. Metabolic acidosis occurs as a result of increased endogenous acid production, a decrease in bicarbonate, or a buildup of endogenous acids.1 Ketoacidosis is a metabolic disorder in which regulation of ketones is disrupted, leading to excess secretion, accumulation, and ultimately a decrease in the blood pH.2 Acidosis is defined by a serum pH <7.35, while a pH <6.8 is considered incompatible with life.1,3 Ketone formation occurs by breakdown of fatty acids. Insulin inhibits beta-oxidation of fatty acids; thus, low levels of insulin accelerate ketone formation, which can be seen in patients with diabetes. Extr Continue reading >>

Extreme Insulin Resistance In A Patient With Diabetes Ketoacidosis And Acute Myocardial Infarction

Extreme Insulin Resistance In A Patient With Diabetes Ketoacidosis And Acute Myocardial Infarction

Case Reports in Endocrinology Volume 2013 (2013), Article ID 520904, 7 pages 1Division of Endocrinology, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA 2Division of Endocrinology, Maimonides Medical Center, Brooklyn, NY 11219, USA Academic Editors: O. Isozaki, W. V. Moore, and R. Murray Copyright © 2013 Yin H. Oo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Hyperglycemia is common in hospitalized patients and associated with adverse clinical outcomes. In hospitalized patients, multiple factors contribute to hyperglycemia, such as underlying medical conditions, pathophysiological stress, and medications. The development of transient insulin resistance is a known cause of hyperglycemia in both diabetic and nondiabetic patients. Though physicians are familiar with common diseases that are known to be associated with insulin resistance, the majority of us rarely come across a case of extreme insulin resistance. Here, we report a case of prolonged course of extreme insulin resistance in a patient admitted with diabetic ketoacidosis (DKA) and acute myocardial infarction (MI). The main purpose of this paper is to review the literature to identify the underlying mechanisms of extreme insulin resistance in a patient with DKA and MI. We will also briefly discuss the different clinical conditions that are associated with insulin resistance and a general approach to a patient with severe insulin resistance. 1. Introduction In hospitalized patients, the development of transient insulin resistance related to different medical conditions such as acute myocardial infarction (MI), sepsis, and Continue reading >>

Steroid Induced Diabetic Ketoacidosis In Patient With Diabetes Mellitus-type 2

Steroid Induced Diabetic Ketoacidosis In Patient With Diabetes Mellitus-type 2

Objective Diabetic ketoacidosis is usually associated with type 1 diabetes; however, it is increasingly being recognized in patients with type 2 diabetes mellitus. Triggering factors usually involve infections and poor medication adherence. Other potential triggers reported are myocardial infarction, antipsychotic drug usage, malignancy and cerebrovascular accidents. No case of steroid induced diabetic ketoacidosis in a patient with type 2 diabetes mellitus has been reported in the literature. Methods Clinical and laboratory data are presented. Results We present a case of a middle age patient with a history of well-controlled type 2 diabetes on metformin, who was started on oral prednisone for lumbar disc herniation and presented with acute diabetic ketoacidosis. No other trigger for diabetic ketoacidosis but steroid initiation was found. Conclusion We concluded that patients with diabetes who receive glucocorticoids should be monitored carefully, as steroids can precipitate DKA, in the absence of any other triggering factor, even in patients with well-controlled type 2 diabetes. Continue reading >>

Clinical Communication: Adults Pseudo-myocardial Infarction In Diabetic Ketoacidosis With Hyperkalemia

Clinical Communication: Adults Pseudo-myocardial Infarction In Diabetic Ketoacidosis With Hyperkalemia

Abstract Hyperkalemia-induced electrocardiogram changes such as dysrhythmias and altered T wave morphology are well described in the medical literature. Pseudo-infarction hyperkalemia-induced changes are less well known, but present a unique danger for the clinician treating these critically ill patients. This article describes a case of pseudo anteroseptal myocardial infarction in a type 1 diabetic with hyperkalemia. The most common patterns of pseudo-infarct and their associated potassium concentrations are then summarized from a literature review of 24 cases. Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Initial Evaluation Initial evaluation of patients with DKA includes diagnosis and treatment of precipitating factors (Table 14–18). The most common precipitating factor is infection, followed by noncompliance with insulin therapy.3 While insulin pump therapy has been implicated as a risk factor for DKA in the past, most recent studies show that with proper education and practice using the pump, the frequency of DKA is the same for patients on pump and injection therapy.19 Common causes by frequency Other causes Selected drugs that may contribute to diabetic ketoacidosis Infection, particularly pneumonia, urinary tract infection, and sepsis4 Inadequate insulin treatment or noncompliance4 New-onset diabetes4 Cardiovascular disease, particularly myocardial infarction5 Acanthosis nigricans6 Acromegaly7 Arterial thrombosis, including mesenteric and iliac5 Cerebrovascular accident5 Hemochromatosis8 Hyperthyroidism9 Pancreatitis10 Pregnancy11 Atypical antipsychotic agents12 Corticosteroids13 FK50614 Glucagon15 Interferon16 Sympathomimetic agents including albuterol (Ventolin), dopamine (Intropin), dobutamine (Dobutrex), terbutaline (Bricanyl),17 and ritodrine (Yutopar)18 DIFFERENTIAL DIAGNOSIS Three key features of diabetic acidosis are hyperglycemia, ketosis, and acidosis. The conditions that cause these metabolic abnormalities overlap. The primary differential diagnosis for hyperglycemia is hyperosmolar hyperglycemic state (Table 23,20), which is discussed in the Stoner article21 on page 1723 of this issue. Common problems that produce ketosis include alcoholism and starvation. Metabolic states in which acidosis is predominant include lactic acidosis and ingestion of drugs such as salicylates and methanol. Abdominal pain may be a symptom of ketoacidosis or part of the inci Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Diabetic ketoacidosis is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with significant fluid and electrolyte loss. DKA occurs mostly in type 1 diabetes mellitus (DM). It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia. Diabetic ketoacidosis (DKA) is most common among patients with type 1 diabetes mellitus and develops when insulin levels are insufficient to meet the body’s basic metabolic requirements. DKA is the first manifestation of type 1 DM in a minority of patients. Insulin deficiency can be absolute (eg, during lapses in the administration of exogenous insulin) or relative (eg, when usual insulin doses do not meet metabolic needs during physiologic stress). Common physiologic stresses that can trigger DKA include Some drugs implicated in causing DKA include DKA is less common in type 2 diabetes mellitus, but it may occur in situations of unusual physiologic stress. Ketosis-prone type 2 diabetes is a variant of type 2 diabetes, which is sometimes seen in obese individuals, often of African (including African-American or Afro-Caribbean) origin. People with ketosis-prone diabetes (also referred to as Flatbush diabetes) can have significant impairment of beta cell function with hyperglycemia, and are therefore more likely to develop DKA in the setting of significant hyperglycemia. SGLT-2 inhibitors have been implicated in causing DKA in both type 1 and type 2 DM. Continue reading >>

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