A 14-year-old male is brought to the ER being found unresponsive.

Question

Diabetes mellitus

A 14-year-old male is brought to the ER being found unresponsive. The patient’s mother, who had not seen the child for over 24 hours, came home to find her son lying on the sofa unresponsive. Copious quantities of black colored vomit were evident. The child is a diabetic and gives himself his own medication. His mother was unsure when her son last took his medication. Blood pressure: 101/72; heart rate: 123; respirations: 32; oral temperature: 34.8°C;pulse oximetry: 100% on room air.

General: An approximately 65 Kg, thin male who is, in general, responsive only to very loud or painful stimuli. His oropharynx demonstrates very dry mucous membranes and a moderate amount of dried, black material which is strongly Gastrocult positive. His lungs are clear, but display Kussmaul respiratory pattern. Abdomen exam is negative. There are no other pathological findings.

1.    How would you proceed from here? Does this patient need an IV? If so, what types of fluid do you want to initiate and at what rate?

2.    What basic lab tests would you order?

3.    In addition to saline the patient was given a bolus of 10 units of regular insulin IV while waiting for the lab results, do you find it necessary, too risky?

4.    A serum glucose determination (Accucheck) was too high to read. How does this affect your differential diagnosis? What additional care would you now render this patient?

5.    The results came back shortly thereafter, and showed an arterial blood gas pH of 6.92, CO2 of 9 and a bicarb of 2. The WBC count was 62.6 thousand (62,600), hemoglobin of 14.4 mg/dL, and hematocrit of 43.5%. His chemistry panel demonstrated a serum sodium of 127, potassium 5.2, chloride of 87, CO2 of less than 5, BUN of 32, creatinine 1.5, and a blood sugar of 1,582. The serum ketones were positive at a dilution of 1:32. What is your interpretation of these results? What additional treatment would you add?

a.    Blood sugar

b.    Serum ketones

c.    Dehydration

d.    Electrolyte changes; What type of acidosis is this?

e.    BUN and creatinine

f.      WBC

6.    What might trigger a DKA?

7.    Would you administer antibiotics?

Answer 1

1. Consider the patient's vital signs and history. Is the patient exhibiting signs and symptoms of shock that would indicate a need for fluid resuscitation? If so, what type of shock is it? If you want to administer fluids, what fluids are available to you, and which seem most appropriate? Would you want to give this patient D10/D50? What about saline or lactated ringers? If you are administering fluids, you will need to calculate an appropriate rate based on the type of fluid, your working diagnosis, and the patient's weight.
2. Consider the patient's pertinent history. He is a diabetic with questionable medication compliance, and he was vomiting dark blood. What lab tests could you order that would be relevant to the patient's condition?
3. Was insulin one of the medications you considered? Would are the pros and cons of a rapid bolus of insulin? Was this an appropriate dose for this patient's weight?
4. Does this information affect your response to the previous two questions? What differential should you always suspect from a high glucose reading?
5. Evaluate the results. Have you memorized normal value ranges for these labs? Which ones are too high, too low, or normal, and what does this tell you about the patient's condition? What is your working diagnosis?
6. This question requires you to again consider the patient's history as well as the lab results. Was the DKA caused by noncompliance? Sepsis? Something else?
7. Is the patient septic? Consider vital signs and lab results. What are the criteria for sepsis? Does a WBC over 62000 indicate infection? Do you need lactate to confirm sepsis?