# EMS treatment of DKA



## abckidsmom (Jan 30, 2011)

The blood glucose thread got me to thinking...for patients in true DKA, is there anything EMS should be/could be doing for them except giving fluid?  I really never experienced in-hospital management of DKA, the only hyperglycemia I saw was related to sepsis, and was "just" stressed out hyperglycemia.

Should we be considering bicarb (with medical control, I guess)?  I've only ever seen sick, sick people with DKA in an urban environment, and we only had a 5 minute transport time.  Now, in a rural environment, the hour we drive to the hospital seems like a long, long ride looking at someone breathing 50/min, acidotic and hypotensive.  The last DKA patient I saw had a pH of 6.8 in the ER (STILL AWAKE!!!), that's not really compatible with long-term life, right?

Hey, smart guys...what are your thoughts?


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## Veneficus (Jan 30, 2011)

I think there are lots of things EMS could be doing for a number of disease processes prehospital. But I have given up trying to implement it because of the responsibility and education adverse environment.

As for this specific question. I have an N=1 experience of bringing somebody out of an arrest using bicarb who we found out on follow up was DKA. (discharged neuro intact I would like to say, one of those times when the stars all align and things turn out great, but I will save it here) So I am somewhat supportive of the idea, but it is not for all patients.

I think as with all patients, it is specific to the case.

Should we be giving bicarb to every DKA patient? Of course not.

Should we be attempting it in the immediate pre-arrest state? certainly, it is much easier to save a life than it is to resurrect somebody.

But look how it plays out:

EMS takes somebody's capilary blood glucose level.(CBG) It reads "high." 

We all know that slowly bringing somebody's blood sugar back to normal is more beneficial than a rapid change. (If you didn't know just nod and pretend you did.)

So many providers will try to quantify it by protocol instead of presentation. It turns into some medics thinking: "If: CBG reading high then: save life by administering bicarb." Which is clearly not regularly the best idea or even indicated. 

So you risk gross over treatment which has iatrogenic conseqences in a majority of cases. Especially from providers who think performing every procedure, administering every drug, or blindly following every protocol because they can is good medicine.   

Calling med control is usually an option in the US. Why not execise that option anytime? Why does there need to be a protocol for it?

Protocols are written for the lowest common denominator, not for the most capable. While I agree in limited cases there can be merit to the treatment, I don't think making it a protocol is a very good idea.


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## zzyzx (Jan 30, 2011)

Veneficus wrote, "I think there are lots of things EMS could be doing for a number of disease processes prehospital. But I have given up trying to implement it because of the responsibility and education adverse environment."

Veneficus, I'm curious, what are those things that you've been considering?


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## WTEngel (Jan 30, 2011)

To determine whether a patient truly has DKA In the field is not possible for most pre hospital providers. Without testing for ketones and being able to check a blood gas, it wouod only be an assumption.

With that in mind, I think bicarb in the pre hospital setting for general use is not a great idea. Without knowing how profound the acidosis is, how far the dissociation curve has shifted, and many other parameters, we really don't have a good target for therapy, and no real quantifiable goals. There has also been evidence that in some instances bicarb can possibly lead to increased ICP. I guess long story short, bicarb is a mixed bag, and most services don't have the ability to adequately monitor all the necessary parameters to effectively use it pre hospital. 

In my experience, the fluids and electrolytes that have the most benefit in DKA tend to be potassium and NS. Hypertonic saline is nice too if you think the patient is at risk for herniation or exhibiting s/s of increased ICP.

One issue I have had with the management of DKA (especially in peds) is the tendency to aggressively fluid resuscitate (which is usually necessary) but typically with the wrong fluids, and simply with the goal of dramatic reduction in BGL. I used to go to referral facilities who were so proud of how fast and far they had reduced the patient's BGL, only to have to hang insulin and d5w behind them, and they just didn't understand. 

The bottom line is DKA is complicated, and there are lots of parameters to look at. The vast majority of people look at only one parameter, BGL. Pre hospital needs to focus on treatment of ABCs and shock, and let ICU and endocrine come up with a plan to correct BGL, acidosis, electrolyte imbalance, etc. Unless you are a CC team with access to iStat blood analyzers for repeat gas analysis, and multiple fluid selections including insulin, potassium, hypertonic saline, etc. don't sweat it and get them to a hospital fast.


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## abckidsmom (Jan 30, 2011)

Veneficus said:


> I think there are lots of things EMS could be doing for a number of disease processes prehospital. But I have given up trying to implement it because of the responsibility and education adverse environment.



I wouldn't mind following this bunny trail too...



> Calling med control is usually an option in the US. Why not execise that option anytime? Why does there need to be a protocol for it?
> 
> Protocols are written for the lowest common denominator, not for the most capable. While I agree in limited cases there can be merit to the treatment, I don't think making it a protocol is a very good idea.



I didn't mean making a protocol.  I just meant "consider" in the literal sense.  Forgive my ignorance, but how does a pre- or peri- arrest DKA patient look, without a ton of monitoring devices...acidotic and hypoperfused?  Can you look at perfusion, mental status, respiratory and heart rate and see that things are running amok?  

What else are you looking for, in the complete absense of abgs and labs.  HI on the glucometer, (typically) a several-day history of hyperglycemic symptoms, hr > 120-130s-ish with ectopy, rr > 40s-ish, sbp < 90s ish, etco2 > 80-100s ish, poorly hydrated, etc...

How sick is "pre-arrest"?  

And this is all for discussion...of course we're talking about consulting medical command at the time of the interaction with the patient to get "legal" advice.


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## Veneficus (Jan 31, 2011)

real quickly this morning.

I would call the peri arrest high blood sugar with a GCS of 5 or less, hx of DM I or II, profound attempts at respiratory compensation, and with hypotension and or rythm disturbance.


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## Sandog (Jan 31, 2011)

Just talking out my arse here, but could you not detect DKA using some sort of DKA breathalyzer, ie detect ketones?


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## JPINFV (Jan 31, 2011)

DKA breathalyzer? Like your olfactory nerves?


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## Sandog (Jan 31, 2011)

JPINFV said:


> DKA breathalyzer? Like your olfactory nerves?



Exactly, but something more precise. My sniffer is not so good.


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## Veneficus (Jan 31, 2011)

*expanded role of EMS*

I looked into the technicalities of EMS activation of the OR or PCI lab. Possible, even done in some places, issue: lack of education and will to be held accountable for improper/over activation.

EMS cleaning and closure of simple lacerations, issue: lack of education.

EMS administration of antibiotics, issue, lack of education.

EMS use of POC lab devices, issue, lack of proper control testing and oversight. (no responsibility)

EMS use of epi for control of hemorrhage, issue, lack of will from med scontrol. 

EMS treat and release, lack of education, responsibility, and lack of interest by all parties.

EMS alternative destination transport. More of the same.

EMS foley placement, lack of interest, responsibility, skill, and education. (some would ask why you would want to do this, but when you give furosimide on a long transport, you will not wonder anymore.) Besides Urine output is a wonderful thing to actually measure qualitatively and quantitatively. "pissed all over the cot" doesn't really approximate well.

Some probably will argue there is a lack of reimbursement. Because these things are not done, there is no reason to list them. Plus in the both private and municiple services, there is a lot of eating costs that are never paid. Let's face it, at some point, it pays to just fix the issue instead of transporting, diagnostics and other consumables, and not getting paid. Especially with the current cost of fuel.

There are probably a few I have forgotten over the years. I am rather impressed with the new pocket sized ultrasound too.


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## J. Burdett (Feb 8, 2011)

WTEngel said:


> One issue I have had with the management of DKA (especially in peds) is the tendency to aggressively fluid resuscitate (which is usually necessary) but typically with the wrong fluids, and simply with the goal of dramatic reduction in BGL. I used to go to referral facilities who were so proud of how fast and far they had reduced the patient's BGL, only to have to hang insulin and d5w behind them, and they just didn't understand.



I hear ya! I had one RN that actually said to me "We should just load the kid up on insulin and be done with it". I tried to explain how metabolization of glucose causes a hypo-osmolar fluid shift and how it can cause ICP.... I didn't get very far in my explanation


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## bigbaldguy (Feb 12, 2011)

Veneficus said:


> We all know that slowly bringing somebody's blood sugar back to normal is more beneficial than a rapid change. (If you didn't know just nod and pretend you did.)
> 
> .



"Nods head"


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