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Why Is Dka A Medical Emergency

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 >>

What Would Happen To An Astronaut Aboard The Space Station If He/she Suffered A Serious Medical Emergency Such As A Ruptured Appendix Or Stroke?

What Would Happen To An Astronaut Aboard The Space Station If He/she Suffered A Serious Medical Emergency Such As A Ruptured Appendix Or Stroke?

They would almost certainly suffer significantly higher morbidity (complications) than if they were on earth. In a true medical emergency, chances of death would be high. The ISS is not adequately equipped to handle a medical emergency, nor are the crew fully trained in medical resuscitation. While there is an assortment of medications on board (mostly in tablet/capsule form), as well as an ultrasound that can be used with remote guidance, it's not an ER. Someone who is critically ill needs at least one physician, at least one nurse, at least one pharmacist, likely multiple concurrent medications, immediate diagnostics, continuous vital sign monitoring, and possible procedural intervention (such as intubation or central venous catheter placement). At this time, an emergency return to earth from the ISS provides little to none of those, and instead requires the injured/ill crewmember to: fold into the confined 3 cubic meter space of the Soyuz along with 2 other crew members who will be focused on orbital re-entry, not medical care endure a 4-9 G re-entry, violent landing, and post-landing dynamics, all without medical monitoring or resuscitation wait in the vehicle until rescue/paramedic forces arrive experience manual extraction from the capsule undergo helicopter transport to medical facilities in...Kazakhstan? Even in ideal situations, this process would delay care at least a few hours, if not several, further increasing the risk to the astronaut for health complications and/or death. One of the current ongoing areas of active research is how we can expand medical capabilities in space despite the numerous challenges, e.g. cargo size (more equipment = more weight = more expensive to blast into space), pharmaceutical degradation (see Evaluation of Physical and Chemical Continue reading >>

Diabetic Ketoacidosis - Symptoms

Diabetic Ketoacidosis - Symptoms

A A A Diabetic Ketoacidosis Diabetic ketoacidosis (DKA) results from dehydration during a state of relative insulin deficiency, associated with high blood levels of sugar level and organic acids called ketones. Diabetic ketoacidosis is associated with significant disturbances of the body's chemistry, which resolve with proper therapy. Diabetic ketoacidosis usually occurs in people with type 1 (juvenile) diabetes mellitus (T1DM), but diabetic ketoacidosis can develop in any person with diabetes. Since type 1 diabetes typically starts before age 25 years, diabetic ketoacidosis is most common in this age group, but it may occur at any age. Males and females are equally affected. Diabetic ketoacidosis occurs when a person with diabetes becomes dehydrated. As the body produces a stress response, hormones (unopposed by insulin due to the insulin deficiency) begin to break down muscle, fat, and liver cells into glucose (sugar) and fatty acids for use as fuel. These hormones include glucagon, growth hormone, and adrenaline. These fatty acids are converted to ketones by a process called oxidation. The body consumes its own muscle, fat, and liver cells for fuel. In diabetic ketoacidosis, the body shifts from its normal fed metabolism (using carbohydrates for fuel) to a fasting state (using fat for fuel). The resulting increase in blood sugar occurs, because insulin is unavailable to transport sugar into cells for future use. As blood sugar levels rise, the kidneys cannot retain the extra sugar, which is dumped into the urine, thereby increasing urination and causing dehydration. Commonly, about 10% of total body fluids are lost as the patient slips into diabetic ketoacidosis. Significant loss of potassium and other salts in the excessive urination is also common. The most common Continue reading >>

Ebm Diabetic Ketoacidosis

Ebm Diabetic Ketoacidosis

Epidemiology New diagnosis of diabetes 10-27%. Infection ~ 35%, inadequate insulin ~ 30%, surgery, trauma, alcohol, cocaine and drugs such as steroids, thiazides, sympathomimetics, pentamidine. No cause in 19-38%, but poor compliance / economic reasons frequent. Mortality 1% in adults, but 5% if over 65 years. Also high 15% in patients with hyperglycaemic, hyperosmolar non-ketotic syndrome (HHNS), when BSL usually > 50 mmol/L, more dehydrated with osmolality is > 320 mosm/L – can calculate latter by (2[NA + K] + glucose). Diagnostic Criteria Raised glucose >11.1 mmol/L Acidosis with arterial / venous pH < 7.3, or venous bicarb < 15 mmol/L Ketonaemia or ketonuria (urinalysis may miss 3-beta hydroxybutyrate early). Management / Complications Hypoperfusion Rapid initial crystalloid, especially for significant circulatory insufficiency, at 15-20 mL/kg in first hour ie. 1-1.5 L. Possible role for bicarbonate is in patients with impending cardiovascular collapse, if pH < 6.9. Dilute 100 mmol 8.4% bicarbonate in 250-1000 mL 0.45% NS, and give over 30-60 minutes with 20 mmol K via infusion pump. (Note there are no prospective data concerning bicarbonate use below pH 6.9, and from 6.9-7.1 morbidity and mortality outcomes are equivocal ie. not proven). Fluid replacement Total body water deficit 100 mL/kg, and sodium deficit 7-10 mmol/kg. Restore normal hydration with 0.9% NS at 4-14 mL/kg/hr, to correct estimated fluid deficit over first 24 hours, without exceeding change in osmolality greater than 3 mOsm/kg per hour. One regime is NS 1000 mL in first hour, 500 mL/hr next 4 hours, then 250 mL/hr next 4 hours ie. around 4 L in first 9 hours. Aim to restore fluid deficits over 24 hours in adults, or up to 48 hours in children. Insulin infusion Insulin infusion at 0.1 units/kg/hr Continue reading >>

Hyperglycemic Emergencies

Hyperglycemic Emergencies

Lana Kravarusic Doctor of Pharmacy Candidate, University of Florida Introduction Diabetes mellitus, if uncontrolled, may lead to serious hyperglycemic emergencies. The two most serious hyperglycemic emergencies are diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS). (Hyperglycemic hyperosmolar state is synonymous with hyperosmolar syndrome and hyperglycemic hyperosmolar nonketotic state which are both older names.) DKA most commonly occurs in patients with Type 1 diabetes mellitus or pancreatic disease, while HHS occurs more frequently with Type 2 diabetes. The presentation of the two syndromes can be distinguished by several factors. Both DKA and HHS patients present with hyperglycemia, but DKA is characterized by ketonemia, ketonuria, and metabolic acidosis while HHS involves dehydration without significant ketoacidosis. It is also possible that a patient presents with a mixture of DKA and HHS.1 The incidence of DKA is estimated to be 4-8 per 1000 diabetic patients, but is likely an underestimation. Up to 25% of cases in the United States are discovered at diagnosis, especially in younger children. The current mortality rate is 2-5% with treatment, and is usually a result of the underlying associated illnesses rather than DKA itself.2 For example elderly patients (>65 years) may have a mortality rate as high as 20% due to comorbid conditions. In some rare cases, however, mortality is a result of a DKA complication such as cerebral edema which is estimated to occur in 0.7-1% of DKA cases in young adults and children. Therefore, children less than 5 years of age and elderly over the age of 65 are considered high-risk DKA patients.1 Currently, the incidence of HHS in the United States is thought to be less than 1 per 1000-person years, making HHS much Continue reading >>

National Study Of U.s. Emergency Department Visits With Diabetic Ketoacidosis, 1993–2003

National Study Of U.s. Emergency Department Visits With Diabetic Ketoacidosis, 1993–2003

Patients with diabetic ketoacidosis (DKA) are often managed in the emergency department before hospital admission. DKA hospitalizations comprise a significant portion of health care costs for diabetes (1). Although mortality for DKA has fallen, it remains an important cause of diabetes-associated death, especially among younger patients with diabetes (2). Prior analyses of DKA have been single-center intensive care unit (ICU) studies or based on hospital discharges (3–5). Patients may, however, be treated in the emergency department and then admitted to a non-ICU setting or discharged; the frequency of these practices is not known. We sought to describe the epidemiology of emergency department visits with DKA. RESEARCH DESIGN AND METHODS— We analyzed the emergency department component of the 1993–2003 U.S. National Hospital Ambulatory Medical Care Survey (NHAMCS). Our institutional review board waived review of this analysis. Methodological details are described elsewhere (6–8). Briefly, NHAMCS uses a four-stage sampling strategy covering geographic primary sampling units, hospitals within primary sampling units, emergency departments within hospitals, and patients within emergency departments. Hospitals were stratified by region, presence of emergency department, ownership type, and size. Within each stratum, hospitals were selected with a probability proportional to the number of emergency department visits. Data were collected during randomly assigned 4-week periods. Data forms include demographic information, emergency department disposition (i.e., admission, transfer, and discharge), and up to three ICD-9 discharge diagnoses. For the present analysis, we identified DKA visits based on ICD-9 code 250.1x, the unique code for DKA, in any of the diagnosis field Continue reading >>

Management Of Diabetic Ketoacidosis

Management Of Diabetic Ketoacidosis

Donahey, Elisabeth PharmD, BCPS; Folse, Stacey PharmD, MPH, BCPS Section Editor(s): Weant, Kyle A. PharmD, BCPS; Column Editor Diabetes, a chronic medical condition, continues to increase in prevalence. One of the most severe complications of diabetes, diabetic ketoacidosis (DKA), results from insulin deficiency and is a medical emergency that is frequently encountered in the emergency department. Prompt diagnosis, assessment of key laboratory values, appropriate treatment, and close monitoring are important to the successful treatment of this complex metabolic disorder. Fluid repletion and insulin administration are mainstays of DKA treatment and serve to restore normal hemodynamic status while decreasing the metabolic acidosis. Careful monitoring of glucose concentrations, vital signs, and electrolytes is essential to prevent complications arising from the treatment of DKA. This article provides an overview of the pathophysiology, presentation, diagnosis, treatment, monitoring, and complications of DKA. © 2012 Lippincott Williams & Wilkins, Inc. Continue reading >>

Diabetic Ketoacidosis (dka) Myths

Diabetic Ketoacidosis (dka) Myths

Recently, I was asked to give a lecture to both my residents and nurses at the University of Texas Health Science Center at San Antonio (UTHSCSA) on some common DKA myths. Now this topic was originally covered by my good friend Anand Swaminathan on multiple platforms and I did ask his permission to create this blogpost with the idea of improving patient care and wanted to express full disclosure of that fact. I specifically covered four common myths that I still see people doing in regards to DKA management: We should get ABGs instead of VBGs After Intravenous Fluids (IVF), Insulin is the Next Step Once pH <7.1, Patients Need Bicarbonate Therapy We Should Bolus Insulin before starting the infusion DKA Myths Case: 25 y/o female with PMH of Type I DM who presents via EMS with AMS. Per EMS report, the patient ran out of her insulin 3 days ago….. Vital Signs: BP 86/52 HR 136 RR 30 O2Sat 97% on room air Temp 99.1 Accucheck: CRITICAL HIGH EMS was not able to establish IV access, so decided to just bring her to the ED due to how sick she looks. Your nurses are on point today and get you two large bore 18G IVs and start to draw blood work to send to the lab. You state I need a blood gas, and the nurse turns to you and asks do you need an ABG or VBG? Myth #1: We should get ABGs instead of VBGs in DKA So you do a literature review and come across two studies that specifically look at ABG vs VBG in an ED population: Study #1: Kelly AM et al. Review Article – Can Venous Blood Gas Analysis Replace Arterial in Emergency Medical Care. Emery Med Australas 2010; 22: 493 – 498. PMID: 21143397 For pH, 3 studies of patients with DKA (265 patients) were reviewed showing a weighted mean difference of 0.02 pH units. Only one study, which was the largest study (200 patients) reported 95% Continue reading >>

Diabetic Ketoacidosis Treatment & Management

Diabetic Ketoacidosis Treatment & Management

Approach Considerations Managing diabetic ketoacidosis (DKA) in an intensive care unit during the first 24-48 hours always is advisable. When treating patients with DKA, the following points must be considered and closely monitored: It is essential to maintain extreme vigilance for any concomitant process, such as infection, cerebrovascular accident, myocardial infarction, sepsis, or deep venous thrombosis. It is important to pay close attention to the correction of fluid and electrolyte loss during the first hour of treatment. This always should be followed by gradual correction of hyperglycemia and acidosis. Correction of fluid loss makes the clinical picture clearer and may be sufficient to correct acidosis. The presence of even mild signs of dehydration indicates that at least 3 L of fluid has already been lost. Patients usually are not discharged from the hospital unless they have been able to switch back to their daily insulin regimen without a recurrence of ketosis. When the condition is stable, pH exceeds 7.3, and bicarbonate is greater than 18 mEq/L, the patient is allowed to eat a meal preceded by a subcutaneous (SC) dose of regular insulin. Insulin infusion can be discontinued 30 minutes later. If the patient is still nauseated and cannot eat, dextrose infusion should be continued and regular or ultra–short-acting insulin should be administered SC every 4 hours, according to blood glucose level, while trying to maintain blood glucose values at 100-180 mg/dL. The 2011 JBDS guideline recommends the intravenous infusion of insulin at a weight-based fixed rate until ketosis has subsided. Should blood glucose fall below 14 mmol/L (250 mg/dL), 10% glucose should be added to allow for the continuation of fixed-rate insulin infusion. [19, 20] In established patient Continue reading >>

Children's Hospital Of Philadelphia

Children's Hospital Of Philadelphia

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact us. ©2017 by Children's Hospital of Philadelphia, all rights reserved. Use of this site is subject to the Terms of Use. The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located. Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient. Continue reading >>

Diabetic Ketoacidosis Symptoms

Diabetic Ketoacidosis Symptoms

What is diabetic ketoacidosis? Diabetic ketoacidosis, also referred to as simply ketoacidosis or DKA, is a serious and even life-threatening complication of type 1 diabetes. DKA is rare in people with type 2 diabetes. DKA is caused when insulin levels are low and not enough glucose can get into the body's cells. Without glucose for energy, the body starts to burn fat for energy. Ketones are products that are created when the body burns fat. The buildup of ketones causes the blood to become more acidic. The high levels of blood glucose in DKA cause the kidneys to excrete glucose and water, leading to dehydration and imbalances in body electrolyte levels. Diabetic ketoacidosis most commonly develops either due to an interruption in insulin treatment or a severe illness, including the flu. What are the symptoms and signs of diabetic ketoacidosis? The development of DKA is usually a slow process. However, if vomiting develops, the symptoms can progress more rapidly due to the more rapid loss of body fluid. Excessive urination, which occurs because the kidneys try to rid the body of excess glucose, and water is excreted along with the glucose High blood glucose (sugar) levels The presence of ketones in the urine Other signs and symptoms of ketoacidosis occur as the condition progresses: These include: Fatigue, which can be severe Flushing of the skin Fruity odor to the breath, caused by ketones Difficulty breathing Type 2 Diabetes Diagnosis, Treatment, Medication What should I do if I think I may have, or someone I know may diabetic ketoacidosis? You should test your urine for ketones if you suspect you have early symptoms or warning signs of ketoacidosis. Call your health-care professional if your urine shows high levels of ketones. High levels of ketones and high blood sug Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

A Preventable Crisis People who have had diabetic ketoacidosis, or DKA, will tell you it’s worse than any flu they’ve ever had, describing an overwhelming feeling of lethargy, unquenchable thirst, and unrelenting vomiting. “It’s sort of like having molasses for blood,” says George. “Everything moves so slow, the mouth can feel so dry, and there is a cloud over your head. Just before diagnosis, when I was in high school, I would get out of a class and go to the bathroom to pee for about 10–12 minutes. Then I would head to the water fountain and begin drinking water for minutes at a time, usually until well after the next class had begun.” George, generally an upbeat person, said that while he has experienced varying degrees of DKA in his 40 years or so of having diabetes, “…at its worst, there is one reprieve from its ill feeling: Unfortunately, that is a coma.” But DKA can be more than a feeling of extreme discomfort, and it can result in more than a coma. “It has the potential to kill,” says Richard Hellman, MD, past president of the American Association of Clinical Endocrinologists. “DKA is a medical emergency. It’s the biggest medical emergency related to diabetes. It’s also the most likely time for a child with diabetes to die.” DKA occurs when there is not enough insulin in the body, resulting in high blood glucose; the person is dehydrated; and too many ketones are present in the bloodstream, making it acidic. The initial insulin deficit is most often caused by the onset of diabetes, by an illness or infection, or by not taking insulin when it is needed. Ketones are your brain’s “second-best fuel,” Hellman says, with glucose being number one. If you don’t have enough glucose in your cells to supply energy to your brain, yo 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 >>

What You Should Know About Diabetic Ketoacidosis

What You Should Know About Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a serious condition that can occur in diabetes. DKA happens when acidic substances, called ketones, build up in your body. Ketones are formed when your body burns fat for fuel instead of sugar, or glucose. That can happen if you don’t have enough insulin in your body to help you process sugars. Learn more: Ketosis vs. ketoacidosis: What you should know » Left untreated, ketones can build up to dangerous levels. DKA can occur in people who have type 1 or type 2 diabetes, but it’s rare in people with type 2 diabetes. DKA can also develop if you are at risk for diabetes, but have not received a formal diagnosis. It can be the first sign of type 1 diabetes. DKA is a medical emergency. Call your local emergency services immediately if you think you are experiencing DKA. Symptoms of DKA can appear quickly and may include: frequent urination extreme thirst high blood sugar levels high levels of ketones in the urine nausea or vomiting abdominal pain confusion fruity-smelling breath a flushed face fatigue rapid breathing dry mouth and skin It is important to make sure you consult with your doctor if you experience any of these symptoms. If left untreated, DKA can lead to a coma or death. All people who use insulin should discuss the risk of DKA with their healthcare team, to make sure a plan is in place. If you think you are experiencing DKA, seek immediate medical help. Learn more: Blood glucose management: Checking for ketones » If you have type 1 diabetes, you should maintain a supply of home urine ketone tests. You can use these to test your ketone levels. A high ketone test result is a symptom of DKA. If you have type 1 diabetes and have a glucometer reading of over 250 milligrams per deciliter twice, you should test your urine for keton Continue reading >>

What Are The Common Symptoms Of Type 2 Diabetes?

What Are The Common Symptoms Of Type 2 Diabetes?

India is the diabetes capital of the world. Type 2 diabetes or insulin resistant diabetes is a silent killer. Many people never realize they have diabetes before significant organ damage occurs. The common signs and symptoms include Obesity especially truncal (around the waist or pot belly) is a high risk factor. Polyuria or excessive urination because glucose acts like an osmotic agent in kidney pulling water out. Nocturia or desire to pass urine in night secondary to polyuria. Polydypsia or excessive thirst due to loss of water in urine. Excessive hunger(polyphagia) Some people can also have weight loss. Poor wound healing Fatigue In late stages Visual loss due to retinal damage Kidney failure and hypertension due to kidney damage. Leg ulcers and gangrene due to poor wound healing. Diabetes is an independent risk factor for heart attack and stroke (metabolic syndrome). Diabetics are also more prone for cancers. Diabetic keto acidosis (DKA) is a life threatening medical emergency caused by very high sugar and dehydration. Patient can become comatose, have seizures and have rapid breathing. Many diabetics discontinue medications abruptly without their doctors advice as their blood sugars become normal. These patients may come to the emergency with DKA. Prediabetes or mild diabetes can be controlled with diet and excercise and weight loss. A recent study showed losing 15 kg weight can completely reverse diabetes. Continue reading >>

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