49 yo C/C of N/V x3 days

[mycrofft]

Still could be both.

But cutting to the chase, still you address the dehydration and comfort issues and transport promptly, code 1.

But then, I wonder if ketones in urine would act bateriocidally?

 

[Handsome Robb]

Urinary hx, glucometry and dryness say start IV, transport. I do not know off hand if Zofran interferes with diabetic situations. Do not get into trying to balance insulin in the field, the fluids will keep her going until a nice endocrine lady or guy can get her started where they can teeter-totter her fingersticks versus her insulin.

Now, absent the obvious IDDM and dehydration (which can lead to renal failure), the narcotics could be doing it. I would also ask about dizziness, maybe have her stand under immediate protection and see if she can even stand up; vestibulitis or labrynthitis could be doing it too. Folks with then "dizzybarfs" would not tend to be eating much; if she did have a vertigo AND did her insulin, then it shouldn't be "HI".

Also, other causes have not been ruled out, but the field EMS answer is hydrate, comfort, and drive humanely to the hospital.

She was able to ambulate with assistance to our gurney. We D/C'd the NIBP prior to the move so no orthostatics...partial fail on our part but even then it wouldn't have changed the treatment pattern. I don't remember offhand if the ambulation provoked dizziness or not.

edit: as for the zofran interfering with diabetic situations either. The aggravation of the FDA claimed prolonged QT from zofran along with presumed electrolyte imbalances crossed my mind but no abnormalities were noted on the printed 4-lead strips although it is non-diagnostic.

 

[usafmedic45]

I associated the dark and foul smelling urine with UTI instead of DKA.

Pt states UO is minimal to none and very dark and "stinky",

Myoglobinuria most likely due to rhabdomyolysis.....how long has she been in bed?

DKA, dehydration, and concurrent UTI (considering presentation of UO) possibly.

I'm with you on the first two but I'm not so sure about the third one until I see an UA.

 

[Handsome Robb]

Myoglobinuria.....how long has she been in bed?

Pt stated 4 days but she had been up and about, albeit very minimally.

That's a good thought too, didn't think of that. Rhabdo + DKA could end very badly. She was definitely one of the more sickly patients I have seen in my short career h34r:

 

[mycrofft]

Oh, yeah. With renal shutdown rounding the clubhouse turn.

If they could dip the urine it would test positive for haemoglobin, if the orange tint didn't confound the reading. (Serial dilution in the kitchen sink...nekulturny). But, field treatment the same.

How about hepatic failure? Stink like ammonia, or like foetid urine, or like canned pears? Never mind, the ER will get a suprapubic or a cath catch and have the whole deal on a cracker in no time.

 

[usafmedic45]

Pt stated 4 days but she had been up and about, albeit very minimally.

That's a good thought too, didn't think of that. Rhabdo + DKA could end very badly. She was definitely one of the more sickly patients I have seen in my short career h34r:

Rhabdo even in a patient with normal kidney function and no risk factors for kidney failure is a bad situation.

 

[Handsome Robb]

If they could dip the urine it would test positive for haemoglobin, if the orange tint didn't confound the reading. (Serial dilution in the kitchen sink...nekulturny). But, field treatment the same.

How about hepatic failure? Stink like ammonia, or like foetid urine, or like canned pears? Never mind, the ER will get a suprapubic or a cath catch and have the whole deal on a cracker in no time.

With the chronic pain medication use hepatic failure is a viable option. Pt stated she did not abuse them and with a quick gander at the containers her statement was confirmed. Not to say that she didn't abuse them in the past. Also her husband was *hammered* and this was at around 1300. Without passing judgement this could indicate alcohol abuse with the environment she lived in. They had been married for 20 yrs IIRC.

Rhabdo even in a patient with normal kidney function and no risk factors for kidney failure is a bad situation.

Haha point, set and match. With hyperK I would expect to see a widened QRS and it was not, but again this was a 4-lead.

edit: correct me if I'm wrong about the ECG changes associated with HyperK.

 

[Smash]

It's worth remembering that sepsis does not require hypotension to diagnose (hypotension being a sign of severe sepsis), and that the initial stages of sepsis are typically hyperdynamic, with bounding pulses and good or even high systolic blood pressures.

Sepsis and DKA also like to hang out together causing mischief.

However even if the precipitant was a UTI, (and it is an if, I'm not arguing that UTI is here, merely that one shouldn't write it off automatically) the treatment, particularly from an out of hospital perspective is the largely the same anyway.


Hyperkalemia induced ECG changes depend in part on how high the K is, but yes, wide, slow rhythms occur (amongst other nastiness).

 

[18G]

Hyperkalemia on ECG will vary based on level of K+. Tall, peaked T-waves are one of the earlier signs along with flattened P-waves. As the K+ increases the QRS widens and can turn into what is commonly described as a "sine wave" pattern.