19 Year Old Male ALOC

[Akulahawk]

There is only one (maybe two) good reason to push (and I mean over like 10 minutes) an amp of bicarb, and it isn't for severe acidosis. Absolutely no reason to give an amp of bicarb as a "push" (i.e. faster than 10 minutes).

Would be interesting to see his initial labs (chemistry and ABG) at the ER if you can get them.

I agree, wouldn't recommend giving this kid bicarb pre-hospital without an extremely good reason.

I agree about the bicarb push idea... as in don't. I was thinking perhaps added to a drip so that it goes in slower, or perhaps as a bolus only in a code. In that guy's state, the IVP idea might have been too much of a correction too quickly and caused more problems. That's pretty much what I meant by the bicarb in my post above. The edit time ran out on me before I could edit it to reflect the slow admin or just remember it for crump time idea.

Just for my own education, I'd have loved finding out what his labs were.

 

[Dwindlin]

I agree about the bicarb push idea... as in don't. I was thinking perhaps added to a drip so that it goes in slower, or perhaps as a bolus only in a code. In that guy's state, the IVP idea might have been too much of a correction too quickly and caused more problems. That's pretty much what I meant by the bicarb in my post above. The edit time ran out on me before I could edit it to reflect the slow admin or just remember it for crump time idea.

Just for my own education, I'd have loved finding out what his labs were.

For acid/base purposes, if I'm going to use bicarb my standard is 3 amps in a bag of D5, this gets you a SID close to plasmalyte, and run it at 100 - 200 cc/hr.

Only time I can see pushing an amp is in TCA overdose and impending herniation due to elevated ICP (standard bicarb is 8.4% sodium bicarb, which is crazy hypertonic).

 

[abckidsmom]

I agree about the bicarb push idea... as in don't. I was thinking perhaps added to a drip so that it goes in slower, or perhaps as a bolus only in a code. In that guy's state, the IVP idea might have been too much of a correction too quickly and caused more problems. That's pretty much what I meant by the bicarb in my post above. The edit time ran out on me before I could edit it to reflect the slow admin or just remember it for crump time idea.

Just for my own education, I'd have loved finding out what his labs were.

For the record, I was thinking about adding it into a liter of saline.

But I do understand how sketchy it sounds.

 

[FLdoc2011]

For the record, I was thinking about adding it into a liter of saline.

But I do understand how sketchy it sounds.

Why normal saline? Now you've made it hypertonic.

 

[Akulahawk]

For acid/base purposes, if I'm going to use bicarb my standard is 3 amps in a bag of D5, this gets you a SID close to plasmalyte, and run it at 100 - 200 cc/hr.

Only time I can see pushing an amp is in TCA overdose and impending herniation due to elevated ICP (standard bicarb is 8.4% sodium bicarb, which is crazy hypertonic).

That makes sense, actually.

 

[Dwindlin]

Why normal saline? Now you've made it hypertonic.

This. Need to add bicarb to a hypotonic solution (D5W, D5-1/2NS, 1/2NS, etc.).

 

[abckidsmom]

This. Need to add bicarb to a hypotonic solution (D5W, D5-1/2NS, 1/2NS, etc.).

Got it. I understand that.

Obviously, I don't have a good understanding of that.

 

[Sublime]

I agree that this was probably DKA. Likely, there was something else going on. Outside in 85 degree weather could have pushed his dehydration from compensated to uncompensated. 12 lead would have been nice to have, only to assess for hyperK+, which can occur with DKA or any acidosis. (one of the body's responses to a high H+ is to ramp up H+/K+ exchange transporters - basically, cells will take up H+ and spit out K+.)

Also, if he happened to be down long enough, he could have been hyperthermic (cooking in the sun) and have rhabdo (on the ground, not moving, leading to muscle break down adding to H+ buildup and also hyperK+).

Please correct me if I'm wrong, but isn't hypokalemia more prominent in DKA?


My understanding is the serum K+ levels may present high in early stages of ketotic acidosis due to the shift of K+ from intracellular to extracellular spaces (due to the H/K exchange you mentioned).

In later stages total body K+ becomes low due to osmotic duiresis. I would assume this patient was well into late stage DKA because of his neurological status.

Once again correct me if on wrong on this, but that is my understanding of it.

 

[Dwindlin]

Please correct me if I'm wrong, but isn't hypokalemia more prominent in DKA?


My understanding is the serum K+ levels may present high in early stages of ketotic acidosis due to the shift of K+ from intracellular to extracellular spaces (due to the H/K exchange you mentioned).

In later stages total body K+ becomes low due to osmotic duiresis. I would assume this patient was well into late stage DKA because of his neurological status.

Once again correct me if on wrong on this, but that is my understanding of it.

Yes early on the body will try to compensate for the elevated H+ by exchanging it for K+, so potassium can be elevated. Regardless of labs however they are likely potassium deficient and generally it is added to their fluids because once you start hydrating and giving insulin/dextrose they will correct very quickly.

 

[medicsb]

Please correct me if I'm wrong, but isn't hypokalemia more prominent in DKA?


My understanding is the serum K+ levels may present high in early stages of ketotic acidosis due to the shift of K+ from intracellular to extracellular spaces (due to the H/K exchange you mentioned).

In later stages total body K+ becomes low due to osmotic duiresis. I would assume this patient was well into late stage DKA because of his neurological status.

Once again correct me if on wrong on this, but that is my understanding of it.

As mentioned, it's the whole body K+ that is low (or normal). DKA can have normal serum K+, but they may become hypoK once you correct the acidosis and hyperglycemia. In that case you need to replete the K+. Hypo[electrolyte] or hyper[electrolyte] typically refers to the electrolyte in the blood serum and not the whole body.

 

[Brandon O]

RR=50 and CBG = >600 + ketone warning is a key thing.

You probably know, but just to clarify for anyone unclear, standard glucometers do NOT test for ketones. (There are special ketone strips that do, but you probably don't have 'em.) The "ketones" flag you usually see is just a reminder to consider DKA that kicks in whenever you test a sugar over a certain number (varies by meter, ours is like 300 mg/dl I think, the OP's is apparently 600). It's a reminder, it doesn't add any info.

 

[Akulahawk]

You probably know, but just to clarify for anyone unclear, standard glucometers do NOT test for ketones. (There are special ketone strips that do, but you probably don't have 'em.) The "ketones" flag you usually see is just a reminder to consider DKA that kicks in whenever you test a sugar over a certain number (varies by meter, ours is like 300 mg/dl I think, the OP's is apparently 600). It's a reminder, it doesn't add any info.

It's been so long since I've seen a glucometer in the field that I figured by now they'd not only caution about ketones, they'd also remind the user to wipe off that 1st drop of blood, periodically calibrate themselves, and even cook breakfast when it notices a low reading. :blink:

Seriously though, if my glucometer was prompting for ketones (for whatever reason), I'd take it as a clue that the glucose level was way too high and to check for the presence of ketones... and also to take a step back for a second and be sure that I'm going down the right treatment path.

 

[the_negro_puppy]

You probably know, but just to clarify for anyone unclear, standard glucometers do NOT test for ketones. (There are special ketone strips that do, but you probably don't have 'em.) The "ketones" flag you usually see is just a reminder to consider DKA that kicks in whenever you test a sugar over a certain number (varies by meter, ours is like 300 mg/dl I think, the OP's is apparently 600). It's a reminder, it doesn't add any info.

Yep i've had a pt with a specific Ketone meter that looks similar to a glucometer. It was able to give us a ketone reading.

I think if its over 1.5mmol its pretty indicative of DKA

 

[Handsome Robb]

You probably know, but just to clarify for anyone unclear, standard glucometers do NOT test for ketones. (There are special ketone strips that do, but you probably don't have 'em.) The "ketones" flag you usually see is just a reminder to consider DKA that kicks in whenever you test a sugar over a certain number (varies by meter, ours is like 300 mg/dl I think, the OP's is apparently 600). It's a reminder, it doesn't add any info.

I'm not sure what triggers ours. I've had "HI" readings with and without the warning for ketones.

I like where this thread is going, I'm on my 7th consecutive day, well dads wedding broke it up, and it's past my bedtime and I have to teach dynamic cardiology to the medic class mañana so I will rejoin you ladies and gentleman tomorrow.

 

[Brandon O]

I'm not sure what triggers ours. I've had "HI" readings with and without the warning for ketones.

Would be curious what make and model. It's possible someone has some other fancy-pants diagnostics incorporated into a regular glucometer.

 

[Handsome Robb]

Would be curious what make and model. It's possible someone has some other fancy-pants diagnostics incorporated into a regular glucometer.

Most carry the Bayer Contour glucometer but some medics, myself included, somehow ended up with the Precision Xtra as well, so I have two glucometers. Originally the plan was to test the Precision and potentially replace the Bayers but most preferred the Bayer so there are Xtras floating around. We don't have separate ketone strips for the Xtra though so I'm starting to think you're correct when you're saying they just say ketones as a reminder.

I personally prefer the Contour, it's easier to use, doesn't require coding and in my experience more accurate/consistent.

Unfortunately I wasn't able to get lab values, I didn't get a chance to attempt to follow up for a couple days and no one could remember. The only number the nurse remembered was his VBG was >1300 mg/dL. They admitted him with a Dx of DKA + Sepsis.

I'm having a tough time grasping the hyper vs hypo K in these patients, I would think their blood serum would be hyperK since its not glucose that drives potassium into the cells it's the insulin that causes the shift and since they do not produce insulin and are generally non-compliant with their medications it seems like hyperK would be more common.

With that said, as much fluid as these patients require I could definitely see how during long term treatment hypokalemia would be a concern.

As far as bicarbonate, fixing their pH alone won't fix the problem, I could see how it would be beneficial in conjunction with an insulin drip, and electrolyte replacement therapy but by itself it doesn't seem like it would accomplish anything other than attempting to "fix numbers" and as Veneficious has pounded through my brain, "just because you fixed the numbers doesn't mean you've fixed the problem."

We don't carry hypotonic solutions so a drip wouldn't even be plausible here.

Ill try to answer questions that I remember, I'm on my phone so I can't go back and look while replying.

As far as an EJ, I considered it. He had a great one but with how much he was fighting I didn't want him to jerk and get into his IJ or carotid or poke myself, or cause him more harm. I agree I should've probably gone for a second line, I was really hesitant to drill him due to the infection risk and my assumption that he took crap care of himself. Had I been unable to get the first line it wouldn't be a question but I had a patent, large bore IV that was flowing well. Shoulda paid closer attention I the pressure bag, I got so flustered with his airway I forgot to add pressure to it as the bag emptied. Probably could have gotten a fair amount more on board had I been cognizant of this.

I had a question about ETCO2...Could I have put the online probe in between the mask and bag and gotten an accurate reading off of it? I've heard of people doing this but it seems like you wouldn't get enough airflow during exhalation to get an accurate reading. Please correct me if I'm wrong. At the same time I could see it working because PEEP works just fine provided you keep a solid face-to-mask seal so why wouldn't ETCO2 be the same with a solid seal?

Time out while I smoke my roommate in MLB 2K12 and I'll be back to review the thread and get to the questions I missed.

 

[NomadicMedic]

We use an end tidal nasal cannula under a CPAP mask, NRBs, Neb masks and BVMs. It's usually enough to give you some ETCO2 numbers for trending and see a waveform. It's not a number I'd hang my hat on without question, but when you've got no other real means of assessing ventilation, it's a handy tool.

 

[Dwindlin]

I'm having a tough time grasping the hyper vs hypo K in these patients, I would think their blood serum would be hyperK since its not glucose that drives potassium into the cells it's the insulin that causes the shift and since they do not produce insulin and are generally non-compliant with their medications it seems like hyperK would be more common.

The increased serum potassium is due to the acidosis (H+/K+ exchange), but as said these patients are losing a ton of potassium in the urine. So while their serum potassium remains high (as long as they remain acidotic) if you looked at total body potassium it is likely profoundly low. That will present itself fairly rapidly after you start treatment.

 

[Brandon O]

Most carry the Bayer Contour glucometer but some medics, myself included, somehow ended up with the Precision Xtra as well, so I have two glucometers. Originally the plan was to test the Precision and potentially replace the Bayers but most preferred the Bayer so there are Xtras floating around. We don't have separate ketone strips for the Xtra though so I'm starting to think you're correct when you're saying they just say ketones as a reminder.

I personally prefer the Contour, it's easier to use, doesn't require coding and in my experience more accurate/consistent.

We use the Contour. It's a really good meter for EMS in my opinion -- great range in both directions, high accuracy, no coding, and no error from a lot of the things that typically can cause it.

It looks like the Precision Xtra actually can measure ketones with the same meter, but you still do need separate strips.

 

[SpecialK]

The increased serum potassium is due to the acidosis (H+/K+ exchange), but as said these patients are losing a ton of potassium in the urine. So while their serum potassium remains high (as long as they remain acidotic) if you looked at total body potassium it is likely profoundly low. That will present itself fairly rapidly after you start treatment.

This. One of the effects of DKA is for the shift of potassium to move intracellular via the H+/K+ ATPase which means that in reality their hyperkalaemia is really only high serum potassium as opposed to high total potassium and once you correct the acidosis the potassium falls rapidly; so if you leave your DKA patient in the hallway on an insulin drip and come back they might just have had a hypokalaemic cardiac arrest and died.