DKA gone wrong

Simulation report 1/2/24


In situ sim ED JHC


Hi everyone,

Thank you so much for participating and helping in today’s sim. I hope we all enjoyed the scenario.

In order to share our learning goals, I have formulated a sim report.

Our case:

22-year-old female being brought into hospital post ROSC. She was found by bystanders on the side of road, CPR commenced with a rapid ambulance response however unknown downtime.

She has ID on herself and is known to the system as an IVDU and non-compliant Insulin dependent Diabetic with frequent DKA presentations.

The Ambulance Officers have equipped her with an LMA and an IO during their resuscitative effort.



A and B: vomit around mouth, unprotected airway,

not tolerating airway support, pulling on LMA

Hypoxic and tachypnoeic

C: shocked, hypotensive and tachycardic, reduced cap refill

D:  agitated, reduced GCS,

E: BSL reads high and temp is 33.2

Learning goals:

  1. Setting management priorities

  highly unstable patient, gain control over situation

no ideal drug available however Ketamine thought to be safest (cautious dosing)

 light sedation hopefully buys you time to manage shock (C-A-B-C approach)

 managing shock before RSI will aim for prevention of rearrest

Keep in back of your mind this patient can rearrest ANY TIME

(close eye on pulse status and monitor)


  1. Management of an unstable DKA


manipulation of metabolic state is aimed at stabilization

of the myocardium to prevent rearrest

rapid assessment of metabolic state (vBG will guide management)

 rapid fluid replacement

 administration of CaGluconate and Nabicarbonate

replacement of K as per vBG

 commencement of Insulin infusion when access and hands available


  1. Post Rosc management


 required intubation as remained agitated or not protecting airway

 drug choice (Ketamine Fentanyl and rocuronium high dose)

 be aware of possible raised ICP due to cerebral oedema

neuroprotective intubation as benchmarking


 address possible cause of shock: cardiac stunning, dehydration and acidosis, sepsis, tension Pneumothorax post CPR

 keep patient well perfused,

over vigorous fluid resuscitation can increase likelihood of cerebral oedema,

commencement of adrenaline infusion to counteract shock



 be alert for signs of raised ICP, can be very Suttle in patient who is intubated and relaxed

 labile BP and HR can be only signs

 treat patient in 40-degree upright position with neuroprotective measures

 if signs of raised ICP, reduce amount of fluid resuscitation and consider Mannitol


 keep patient normothermic

For further reading I recommend the following:


Thank you again and please feel free to contact me under if you have any other ideas or questions.


See you again for the next in situ sim,

Irene Pelletier, FACEM