Why confusion with dka

On physical examination, she was alert, dehydrated, had deep sighing respirations and smell of ketones. She had normal body temperature Base excess was Blood urea, liver enzymes and electrolytes were within normal limits Table 1.

At the 6 th hour of treatment, the patient became agitated and tried to get up and walk. She could not be appeased and attacked the staff. She ripped off her infusion sets three times in 30 minutes. A cerebral computed tomography was performed immediately and showed no brain edema or hemorrhage.

In the mean time, the patient was very agitated and we had to strap her to the bed as she injured two nurses. The acidosis could not be corrected because the insulin and fluid therapy was interrupted. At the eighth hour, her Glasgow Coma Scale was 9. In consultation with an anesthesiologist, 1 mg of midazolam was given for sedation, thus, we were able to start an iv line.

At the 10th hour, to correct the acidosis, bicarbonate infusion was initiated with insulin 0. Mannitol infusion was stopped since there was no improvement in consciousness. At the 12 th hour, despite the improvement in acidosis, delirium still persisted. A brain magnetic resonance imaging MRI performed at this time was reported as normal. Substance abuse and drug intoxication were suspected. She was screaming, making incomprehensible sounds and was responding to painful stimuli.

We continued with the same fluid infusion, but the rate of insulin was increased stepwise to 1. At the 16th hour, the blood gas analyses showed a worsening Table 2.

This change was attributed to cessation of insulin and fluid infusion during the MRI. Therefore, the HCO3 infusion was repeated. At the 18 th hour of treatment, the patient developed a high fever. Serum C-reactive protein level was high 7. Samples for blood and urine cultures were taken and iv ceftriaxone was started. Lumbar puncture was considered but postponed due to the instability of the patient.

Retinal examination was normal. At this time, her agitated state disappeared and the patient began to sleep. At the 24th hour, acidosis had resolved completely, but she was still unconscious with little response to verbal stimuli. The patient had vulvovaginitis and treatment with fluconazole was started.

In the following hours, consciousness improved slowly. At the 30 th hour of treatment, she could open her eyes in response to calling her name. Finally, at the 36 th hour, the patient was able to obey commands and sit up. The fluid and insulin infusions were stopped and subcutaneous insulin was started.

The patient could not remember the delirium episode and no neurological sequelae were observed. She was discharged after a few days with complete recovery. We presented an unusual case with delirium due to severe acidosis. Correcting the acidosis alone was not enough to manage the delirium and the treatment was challenging. Delirium in patients treated in intensive care unit has been reported as a common and serious acute brain dysfunction with adverse outcome and high risk of mortality 1.

Delirium is characterized by four features: 1 inattention and disturbance of consciousness, 2 change in cognition, 3 acute onset and fluctuating course, and 4 presence of a pathophysiological cause 2. Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours.

For some, these signs and symptoms may be the first indication of having diabetes. You may notice:. More-specific signs of diabetic ketoacidosis — which can be detected through home blood and urine testing kits — include:.

If you feel ill or stressed or you've had a recent illness or injury, check your blood sugar level often. You might also try an over-the-counter urine ketones testing kit.

Sugar is a main source of energy for the cells that make up your muscles and other tissues. Normally, insulin helps sugar enter your cells. Without enough insulin, your body can't use sugar properly for energy. This prompts the release of hormones that break down fat as fuel, which produces acids known as ketones.

Excess ketones build up in the blood and eventually "spill over" into the urine. Uncommonly, diabetic ketoacidosis can occur if you have type 2 diabetes. In some cases, diabetic ketoacidosis may be the first sign that you have diabetes.

Diabetic ketoacidosis is treated with fluids, electrolytes — such as sodium, potassium and chloride — and insulin. Perhaps surprisingly, the most common complications of diabetic ketoacidosis are related to this lifesaving treatment. Continuously reassess the patient for improvement or deterioration. By understanding the pathophysiology of diabetic ketoacidosis, you should be better prepared to recognize the clinical presentation more promptly, differentiate the condition from other diabetic emergencies and have a good foundation for understanding the emergency care necessary to manage the patient effectively.

Joseph J. He has more than 36 of experience as an EMS educator. He is a frequent speaker at state and national EMS clinical and education conferences. You must enable JavaScript in your browser to view and post comments. More Product news. More Product Originals.

More Ambulance Disposable Supplies Articles. All Distributors. More Ambulance Disposable Supplies Deals. Make EMS1 your homepage. More than EMS courses and videos totaling over continuing edcuation hours! Email Print Comment. Pathophysiology of diabetic ketoacidosis The patient experiencing DKA presents significantly different from one who is hypoglycemic. There are three major pathophysiologic syndromes associated with an excessively elevated blood glucose level in DKA: Metabolic acidosis Osmotic diuresis Electrolyte disturbance Due to the lack of insulin, cells are not receiving an adequate fuel source to produce energy.

The DKA patient is therefore prone to metabolic acidosis from: Ketone production Severe dehydration from osmotic diuresis Electrolyte disturbances These three pathophysiologic syndromes produce the signs and symptoms exhibited by the patient.

DKA emergency care and management As with any patient in the prehospital environment, ensure an adequate airway, ventilation, oxygenation and circulation. Guyton, A. Textbook of Medical Physiology. Philadelphia: W. Sauders, Marx, J. Hockberger, R. Louis: Mosby, Inc. Thank You! About the author Joseph J. Join the discussion. Latest Product News 7 injured in flipped Texas ambulance crash. The pediatric general assessment triangle.

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