This week we discuss how to aggressively resuscitate patients with DKA as well as dispelling some dogmatic teachings on the topic.


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Tags: Cerebral Edema, DKA, Hypokalemia, Insulin, Resuscitation





Show Notes
Take Home Points

DKA should be suspected in any patient with altered mental status and hyperglycemia. Get a VBG (ABG not necessary) to confirm the diagnosis.
Hypokalemia kills in DKA. Aggresively replete potassium and consider holding insulin, which drops serum potassium, until K is greater than 3.5
The insulin bolus isn’t necessary and appears to cause more episodes of hypokalemia. Just start insulin as an infusion at 0.14 units/kg
Be vigilant about cerebral edema. Any change or deterioration in mental status should prompt treatment and evaluation. Mannitol in the euvolemic, normotensive patient and 3% hypertonic saline in the hypotensive/hypovolemic patient
Finally, don’t forge to always hunt down the underlying cause of the DKA. Infection and non-compliance is the most common so liberally administer broad spectrum antibiotics if you’ve got even a hint of infection brewing

Additional Reading
LITFL: EBM Diabetic Ketoacidosis
Core EM: DKA
Core EM: Episode 13.0 - Diabetic Ketoacidosis: A Case
emDocs: Myths in DKA Management
REBEL EM: Is There Any Benefit to an Initial Insulin Bolus in Diabetic Ketoacidosis?
References
Aurora S et al. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med 2012; 30: 481-4. PMID: 21316179
Boyd JC et al. Relationship of potassium and magnesium concentrations in serum to cardiac arrhythmias. Clin Chem 1984; 30(5): 754-7. PMID: 6713638
Duhon B et al. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother 2013; 47: 970-5. PMID: 23737516
Fagan MJ et al. Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry arethey? Clin Ped 2008; 47(9): 851-6. PMID:
Goyal N et al. Utility of Initial Bolus insulin in the treatment of diabetic ketoacidosis.  J Emerg Med 2010; 38(4): 422-7. PMID: