Category Archives: Medical

The daily educational pearl – steps in DKA management

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Steps in DKA management

This post will only detail the steps that you need to make sure you go through when managing a patient with DKA, it will not go into any specific details regarding doses / frequency / timing.

1. Resuscitation / iv fluid therapy

– A/B/C – patients might present with circulatory collapse / altered mental state due to severe acidosis / metabolic disturbances (especially hypo or hyperK)

– early iv fluid resuscitation / therapy is very important; however be aware of the risk of cerebral oedema (especially in children) and exercise caution after the 2nd liter of fluid in adults and in children only give 10 mls/kg boluses then review carefully

2. Insulin therapy

– as per the local protocol; usually 0.05 – 0.1 units/kg/hr; the use of a bolus dose is controversial as it might increase the risk of cerebral oedema

– start with a lower dose in patients in renal failure

3. Dextrose – to start when BSL <15.0 mmol/L; consider using 10% instead of 5% if the patient is fluid overloaded or at risk of cerebral oedema

4. Electrolyte replacement

– K (caution if already low when you start insulin as it will drop further, or if in acute renal failure or anuric)

– phosphate

– Mg

5. Look for the cause of decompensation – infection / CNS event / alcohol binge etc.

6. Monitor closely for complications of therapy – hypoglycaemia / rapid shift in electrolytes with arrhythmia or altered mental state / seizures / cerebral oedema

 

 

 

 

The daily educational pearl – diagnosing diabetes

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When do you diagnose your patient with diabetes?

– fasting plasma glucose > 7 mmol/L

– symptoms + random plasma glucose >11.1 mmol/L

– plasma glucose > 11.1 mmol/L 2 hours after 75 g glucose load

– Hb A1c > 6.5%

If your patient in ED has a random BSL reading > 5.5 mmol/L, they should be referred to their GP to have a fasting BSL done (and if still > 5.5 mmol/L, their GP should organise a glucose tolerance test).

What do you do if you have a patient in ED that you have just diagnosed with diabetes?

First of all, make sure it is truly diabetes. Remember that adrenaline is a hyperglycaemic hormone, so stressful situations (i.e. trauma) will be associated with higher BSL readings (however, the books say it should be less than  10 mmol/L). These patients need close follow-up and fasting BSL + oral glucose tolerance test done after the acute issues are resolved.

Patients who meet the criteria for diabetes need to be admitted if they have complications (i.e. ketones on urine dipstick / serum bicarbonate <22 / abnormal pH / hypo or hyperK / acute renal failure / abnormal mental state) or if they can’t have reliable diabetes education as an outpatient or if it’s likely type I diabetes (young patients) and they need insulin therapy started.

 

 

The daily educational pearl – altered mental state after a witnessed seizure

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Your next patient was witnessed to have a tonico-clonic seizure 30 min ago. He remains GCS 6. Why might that be?

Causes of persisting altered mental state following a seizure

– status epilepticus

– iatrogenic (i.e. given benzodiazepines prehospital or in ED)

– normal postictal state

– persisting cause (of seizure + AMS): hypoNa / hypoglycaemia / toxins / SAH / intracerebral haemorrhage / meningitis / encephalitis

– complications of the ictal state – hypoxic brain injury / severe metabolic acidosis

 

The daily educational pearl – Antibiotic therapy for UTIs

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Current therapeutic guidelines for the management of UTIs in adults

First of all, just as a reminder, if you send the urine off for M/C/S for patients who are discharged home, please document under clinical comments in EDIS what antibiotic you prescribed so that we don’t have to recall the notes every time there is a positive urine culture.

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