Emergency Medicine is Hard

Diabetic Ketoacidosis

Clinical features

  1. BGM >250 mg/dL, unless the patient is on a SGLT-2 inhibitor (-flozin)
  2. HCO3<18
  3. pH≤7.3
  4. Presence of an anion-gap
  5. Ketones detected in the blood or urine

Management

A. Fluids

  • Start with isotonic 0.9% NS
  • When glucose falls to ≤250 mg/dL, change to 5% dextrose in 0.45% NS @ 150-250 cc/hr

B. Insulin

  • Start continuous infusion of IV insulin at 0.1 U/kg/hr if K >3.3 with a glucose goal of 150-200 mg/dL
  • Check glucose q1h (Glucose should fall ~50 mg/dL/hr)
  • When glucose falls to 350 mg/dL, drop insulin infusion rate in half (0.05 u/kg/hr)
  • Start basal insulin 2-3 hours before stopping infusion (Glargine 0.3u/kg SQ or 24 hour home dose)

C. Potassium

  • Check potassium q1h with a goal K of 4-5
  • If K is <3.3, hold insulin and give 40 mEq K
  • If K is between 3.3 and 4.9, add 20-30 mEq of K to each liter of IVF
  • If K is >5, check K q2h
    Alex Yang