At what point do you intervene (DKA with suspected metabolic acidosis)?

[FLdoc2011]

Outside of overt shock or a peri-arrest situation with presumed life threatening hyperkalemia, I don't think there's a role for bicarb for DKA in prehospital setting. Even in the ICU we don't consider it unless pH is <6.9 or we have cardiac instability/shock or hyperkalemia, and even then it's in a solution given over an hour or two.

The Airway issue here is fairly straightforward, use the same general indications for intubation you'd use for other conditions. I'd say that if his mental status has declined to the point of needing BVM then he probably needs to be tubed. Otherwise if he's oxygenating and still awake enough to protect his airway and breath on his own his resp rate will get better with treatment.

Babysat a young DKAer the other night in the ICU who came in breathing 30's, tachy 130's, BP ok, pH 7.05. Everything improved in matter of hours with fluids, lytes, and insulin.

 

[FLdoc2011]

Also keep in mind in either an acidosis or alkalosis the compensatory mechanism will never be enough to return the pH to normal, just isn't going happen. I've seen people look at gas and erroneously think someone is "over" compensating and swung their pH too far the other way.

 

[BLS Systems Limited]

I have a question for those thinking about intubating (and don't have an iStat to check the ABG's). Once you've tubed them, now what? What are your protocols for bagging to maintain EtCO2? Are you going to stick with their original 15 mmHg? Many protocols limit you to 25 mmHg since blowing off too much CO2 can also lead to issues.

 

[Veneficus]

instant gratification...

Could I just point out that since it took hours to days to get to this point, it will take the patient hours to days to get back?

 

[18G]

DKA patients are usually significantly dehydrated from the osmotic diuresis that occurs. They lose lots of fluid and need lots of fluid replacement. The patient presented had tachycardia and borderline hypotension. In the field, this patient would get 1-2 liters of NSS easy.

I would not intervene with the respiratory status of this patient as long as he is protecting his airway. The EtCO2 of 15 is to be expected and this patient needs to be breathing that fast.

 

[Akulahawk]

DKA patients are usually significantly dehydrated from the osmotic diuresis that occurs. They lose lots of fluid and need lots of fluid replacement. The patient presented had tachycardia and borderline hypotension. In the field, this patient would get 1-2 liters of NSS easy.

I would not intervene with the respiratory status of this patient as long as he is protecting his airway. The EtCO2 of 15 is to be expected and this patient needs to be breathing that fast.

The few DKA patients that I have seen emergently ended up getting a 1L NS bolus, possibly 2, and no airway interventions. I typically left long before I could find out which unit the patient had been admitted to... but given that those patients need rehydration, restoration of electrolytes to normal values, insulin administration, and so on, I can only imagine that would be an ICU, at least there long enough so that the patient can stabilize and be transferred to a lower acuity unit.

Also, I figure that if a patient is in DKA and has a low-ish pH and has a low EtCO2, I'm going to want to keep that EtCO2 reading low as it's not measuring the ketones being blown off also in an attempt to compensate (even partially) for the acidosis.

As to what I can do with a DKA patient in the field that isn't unconscious or in shock... not a whole heck of a lot, per protocol. I'd have to call for specific orders for this kind of patient because we have none that specifically addresses DKA or any other hyperglycemic state. Effectively, all I can do is follow protocol for problems that occur as a result of DKA. Just keep 'em comfy and transport if the patient called 911 to begin with. I would think that many of them would seek care on their own before things got bad because they'd probably feel pretty crummy.