Emergency Medicine Emergency Medicine Case DiscussionCase Discussion

Ext. Nuchsarang Udomkaewkanjana

4802050

Patient Profile: หญิ�งไทยคู่� อาย� 70 ปี� Chief Compliant: ซึ�มลง เหนื่��อยมากขึ้��นื่ 1 วั�นื่ PTA

Brief HistoryBrief History • Symptoms • Trauma • Medication • Underlying disease

Primary SurveyPrimary Survey• Airway – clear• Breathing & Ventilation – RR 30 /min O2 sat 97%• Circulation – BP 130/70 mmHg PR 162 bpm, full & regular• Disability – E3V2M5, no evidence of head trauma, no focal

neurodeficit

6.00 PM

• DTX STAT = 388 mg%• O2 Sat = 97%• β-OH butyrate- positive• Urine ketone dipstick- positive

Initial managementInitial management

? DKA ?

6.05 PM

• O2 canula 3 LPM

• IV Fluid- 0.9%NSS 1000 ml/hr

• Retained foley’s cath

• Meropenem 2 g IV STAT

• CBC, BUN, Cr, Electrolyte, Ca, Mg, P, LFT

• UA, U/G, U/C, CXR

• EKG 12 leads, ABG room air, Lactate

• F/U DTX q1h , Elyte at 8 PM

6.10 PM

Present Illness: 1 wk PTA ผู้�ปี วัยมา ER ด้�วัยไขึ้�สูง คู่ล��นื่ไสู�อาเจี$ยนื่ UA – WBC 15-20 dx UTI ได้� Ceftriaxone IV OD *3 d. หล�งจีาก F/U อาการด้$ขึ้��นื่ แต่�ย�งม$ไขึ้� U/C, H/C – NG จี�งได้�เปีล$�ยนื่เปี(นื่ Ciprofloxacin PO *14 d.

1 d PTA ญิาต่�สู�งเกต่วั�าหายใจีเร*วั ซึ�มลง ไม�คู่�อยพูด้ เร$ยกร�ต่�วั ไม�ท,าต่ามสู��ง ไม�ม$ปีระวั�ต่�ศี$รษะกระแทก ไม�ม$ไอ/นื่,�ามก ปี0สูสูาวัะปีกต่� ไม�ปีวัด้ท�อง ไม�ถ่�ายเหลวั ม$ไขึ้�สูง จี�งพูามารพู.

Past Illness: Underlying DM, HT, DLP, distal CBD stricture with obstructive jaundice S/P stent

No drug or food allergy, no smoking and alcoholic drinking

Secondary SurveySecondary Survey 6.20 PM

Physical ExaminationPhysical ExaminationVital Signs: BP 130/70 mmHg RR 30/min PR 162

bpm T 40.1 °CGA: A Thai old woman, drowsiness, tachypnea,

mild jaundiceHEENT: no bruise or petechiae, marked pale

conjunctivae, icteric sclerae

CVS: tachycardia, full and regular pulse, normal s1 s2, no murmur

RS: normal breath sound, no wheezing, no crepitation

GI: soft, no mass, no guardingCNS: E4V5M6, drowiness, pupils 2 MM RTLBE,

motor tone- normal, power gr III at leastExt: no pitting edema

Differential Differential DiagnosisDiagnosis• Intracranial• Extracranial

• DTX = 390 mg%• 0.9% NSS 1000ml

+ KCl 40 mEq IV 100 ml/hr

• 0.9% NSS 1000ml IV 400 ml/hr

• RI 10 u IV push RI 10 u IM

• AG = 19.3

EKG 12 LEADS – Sinus tachycardia rate 160 bpmCXR – no cardiomegaly, no infiltrationUrine – 150 ml clearUA – pH 5.0 spec. 1.019 glucose 4+ protein2+ ketone marked + WBC 0-1 RBC 2-3 ELECTROLYTE 129 3.16 24 89 20.7 1.0

7.20 PM

• DTX = 302 mg%• IV เด้�ม• RI IV drip 0.1 u/kg/hr• F/U elyte• Respiratory alkalosis

with metabolic acidosis• HCO3

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• Consult MED – ย�าย 7NW

CBC10.3 17,550 N 9131.1 229,000 L 5UG- no organism seenABG pH 7.505 pO2 71.3 pCO2 23.8 HCO3

- 18.9Lactate 0.6 mmol/L (5 mg/dl)

8.20 PM

MED noteMED note• Diagnosis : Sepsis with hyperglycemia• DTX = 252 mg%• IV 5%DN/2 + KCl 40 mEq

9.20 PM

ELECTROLYTE 135 2.25 24 100 22.9 1.0

Diagnostic criteria: • serum glucose >250 mg/dl• arterial pH <7.3• serum bicarbonate <18 mEq/l• moderate ketonuria or

ketonemia.

D K AD K A H H S H H S Diabetic KetoacidosisDiabetic Ketoacidosis Hyperosmolar Hyperglycemic StateHyperosmolar Hyperglycemic State

Diagnostic criteria: • serum glucose >600 mg/dl• arterial pH >7.3• serum bicarbonate >15 mEq/l• minimal ketonuria and ketonemia

D K AD K ADiabetic Diabetic

KetoacidosisKetoacidosisInsulin Deficiency

With counteregulatory hormone response

Protein Breakdown

Lipolysis

Hepatic gluconeogenesis

Cellular underutilization of glucose

Loss of nitrogenMuscle wasting

Osmotic diuresis

Hyperglycemia

Ketoacid

Dehydration

SHOCKCompensatory

tachypnea

N/V

Wide AG acidosis

Ketonuria

I V

KK & & RIRI

Monitoring Treatment OutcomeMonitoring Treatment Outcome

Out Of DKA ?• DTX• pH• Serum ketone• Urine ketone• Urine betahydroxybutyrate• AG• HCO3

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Thank You !Thank You !