doc_clotaire
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A 20-year-old female is brought to the Emergency Room by her college roommate who states that the patient vomited all night. The patient complains of a sore throat and says she has not eaten for the last two days. She admits to a "sugar problem" and quit taking her medication because she has not been eating.
Examination reveals an ill-appearing woman.
Her temperature is 37.9 C (100.2 F),
blood pressure is 118/78 mm Hg,
pulse is 160/min,
and respirations are 30/min. The patient's lips and mucous membranes are dry. There is a fruity odor noted to the patient's breath. The lung and cardiac examination are unremarkable except for mild tachypnea and tachycardia. Laboratory analysis shows:
Sodium......................130 mEq/L
Potassium..................6.1 mEq/L
Chloride....................100 mEq/L
Bicarbonate...............8 mEq/L
Urea nitrogen............10 mg/dL
Creatinine.................1.0 mg/dL
Glucose....................680 mg/dL
pH...........................7.15
pCO2.......................30 mm Hg
pO2.........................85 mm Hg
Urinalysis is positive for ketones.
Which of the following is the most appropriate initial step in management?
a)Immediate intubation
b)Intravenous insulin
c)Intramuscular ceftriaxone
d)IV fluid bolus with normal saline and potassium
e) Mannitol
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(b) I/V insulin
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on second thought, i'm confused b/w choices b and d. obviously patient is in DKA, and the management of that warrants immediate attention towards both dehydration and the rising glucose levels. it's simultaneous. but i guess if the stress is on the word "....appropriate INITIAL step.." then perhaps it's choice d.
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| doc_clotaire
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Confusing right  ?????????????????????????????????????????????????????????????????? ?
Make your mind right buddy ? What 's definitly your best option  ?
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| muna
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B
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| sachida
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D is the best initial step
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i think it's D
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| Justice
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I go with (D)
Potassium is increased (which probably confuses most of the people and stops from giving D) but saline bolus will dilute it down, so it would be "safe" to stick to this option... In addition, if (D) is immediately followed by (B), that extra potassium will be needed to cover potential hypokalemia...
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Total body potassium is low in spite of measured hyperkalemia. and ur right, justice, the potassium will fall fast as it enters the cells with glucose. agreed that D should be immed. followed by B. like i said, B and D are simultaneous steps in the management. it's actually the wording of the ques. where the catch is.
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| dr.wad
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i will go with ( B ). it is wise to start treating the cause of the problem.
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so what's the ans. doc_clotaire?
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Explanation from Kaplan
The correct answer is B
Diabetic ketoacidosis (DKA) is a life threatening complication of diabetes mellitus. DKA exists if there is hyperglycemia (glucose >300), ketonemia, acidosis (pH <7.30, HCO3 < 15) with clinical symptoms of diabetes. The mainstay of treatment for DKA is intravenous insulin.
Intubation (choice A) is rarely necessary in DKA patients. The patient is alert enough to give some history and appears to be oxygenating well.
Intramuscular ceftriaxone (choice C) may be necessary in this case to treat an underlying infection, which may have precipitated this episode of DK
A. However, this is certainly not first-line treatment for DKA.
Intravenous fluids (choice D) are also vital for DKA patients, as they are severely dehydrated. However, potassium is not initially added to intravenous fluids, especially if the potassium level is greater than 6.0 mEq/L.
Mannitol (choice E) is used in suspected cases of cerebral edema, a complication of DKA. Clinical signs include deterioration in mental status, headache, and unequal pupils.
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| Justice
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As seen several times, this Kaplan explanation has no link to clinical practice but rather is based on theory... Whereas IV insulin is a mainstay of the treatment (cited) of DM, it is NOT the mainstay for the treatment of DKA where sympoms and hypovolemia will NOT be corrected by giving insulin... Wanna try?
Edited by Justice on 04/18/07 - 11:03 PM
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Colleagues,
check out here: practical recommendations to the treatment of DKA:
http://www.diabetes123.com/d_0n_031.htm
The Barbara Davis Center for Childhood Diabetes in Denver, Colorado, has prepared an excellent poster for hospital emergency rooms with the correct treatment procedures for DKA and suspected cerebral edema. The guidelines are as follows:
Severe DKA:
1. Venous (or arterial) pH < 7.10
2. HCO3 <8 mEq/L
3. Usually large urine ketones on dipstick
4. Breath may have "fruity" odor
5. Often Kassmaul respirations
6. Treat at facility with pediatric ICU
Treatment of DKA:
1. Rehydration: 20 ml/kg bolus in first 1-2 hours (NS or LR)
2. NPO if vomiting
3. Insulin drop: 0.1 U/kg per hour IV
4. If still dehydrated after 1-2 hours: can repeat bolus of 20 ml/kg NS or LR over 1-2 hours--MAXIMUM BOLUS MUST BE <40 ml/kg;; then fluilds (0.45NS) at 1.5 times maintenance. Give no more than 4L of fluid/m2/24 hours (including initial bolus)
5. Add potassium (K+) when pH > 7.1 and serum K+ known to be normal or low (may use 20 mEq/L KPO4 and 20 mEq/L KAc [or KCl])
6. Aim for glucose fall of 100 mg/dl per hour
7. Add 5% dextrose to IV when blood glucose falls to 200-250 mg/dl
8. Repeat electrolytes and venous pH hourly until pH > 7.1; then repeat every 2 hours until > 7.2 and then every 4 hours until > 7.3
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| Justice
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Here is another link to the American Family Physician site...
http://www.aafp.org/afp/20050501/1705.html
read below:
fluids
Fluid deficits are typically 100 mL per kg of body weight.3 Fluid replacement alone will lower blood glucose. Tracer studies have found that during the first four hours of therapy for DKA, up to 80 percent of the decline in glucose concentration may be caused by rehydration.28
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| Justice
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And here is some info from Mayo Clinic:
http://www.mayoclinic.com/health/diabetic-ketoaci...
Treatment
You'll need to begin treatment for diabetic ketoacidosis immediately after diagnosis, because the condition can quickly worsen. Treatment for DKA usually consists of:
* Fluid replacement. As a first step in treating diabetic ketoacidosis, you'll receive fluids, either orally or through a vein in your arm (IV), until your body is rehydrated. Fluid replacement is an important part of DKA treatment because people with diabetic ketoacidosis tend to lose large amounts of fluids. Fluids also help dilute the high levels of glucose in your blood.
*
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| Justice
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Finally, this is the info from MERCK:
http://www.merck.com/mmpe/sec12/ch158/ch158c.html
Prognosis and Treatment
Mortality rates for DKA are between 1 and 10%; shock or coma on admission indicates a worse prognosis. Major causes of death are circulatory collapse, hypokalemia, and infection. Among children with cerebral edema, 57% recover completely, 21% survive with neurologic sequelae, and 21% die.
The most urgent goals of treatment are rapid volume repletion, correction of hyperglycemia and acidosis, and prevention of hypokalemia. Identification of underlying precipitating factors is also important. Treatment should occur in intensive care settings because clinical and laboratory assessments are initially needed every hour or every other hour with appropriate adjustments in treatment.
Volume repletion in adults is typically achieved with rapid IV infusion of 1 to 3 L of 0.9% saline solution followed by saline infusions at 1 L/h or faster as need to raise BP, correct hyperglycemia, and keep urine flow adequate. Adults with DKA typically need a minimum of 3 L of saline over the first 5 h. When BP is stable and urine flow adequate, normal saline is replaced by 0.45% saline. When plasma glucose falls to < 250 mg/dL, IV fluid should be changed to 5% dextrose in 0.45% saline.
All start from IV fluids...
Why Kaplan teaches something different?
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i agree...some of the protocols i went through, also start with fluids
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Take another look in Barbara Davis Poster !
5. Add potassium (K+) when pH > 7.1 and serum K+ known to be normal or low (may use 20 mEq/L KPO4 and 20 mEq/L KAc [or KCl]) . That 's the teaching point Kaplan is tryng to make right here .
Kaplan prepare you to have the correct answer right on the exam , USMLE is not a " REAL LIFE PRACTICE EXAM " if it was , all IMGs attendings would pass it easily without even reading Kaplan or UW . It 's not our way , it 's USMLE way . Period !
There is no such thing as " definitly correct answer " , that means each choice would have something right about it . Ask anyone who already took CK , that 's why every body is saying that EXAM IS VAGUE . You would never be 100 % sure about the correct answer because all look alike .
Every body knows that NSIM of DKA is fluids, no doubt about that and you have to add K even if the level is normal as you correct the metabolic acidosis with normal saline and insulin , the K+ will fall and the patient will be hypokalemic , but you just don ' t add K when the level is above the normal range in USMLE way . That is the take home message that Kaplan is trying to do .
Like I said before , That is a practice test and the correct answer is B
Whether people agree or not is IRRELEVANT and it 's up to every one to digest the information given here ,
Kaplan 's not gonna put a gun in your head to accept it 
Happy Studying Folks !
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| Justice
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doc_clotaire wrote: Take another look in Barbara Davis Poster ! 5. Add potassium (K+) when pH > 7.1 and serum K+ known to be normal or low (may use 20 mEq/L KPO4 and 20 mEq/L KAc [or KCl]) . That 's the teaching point Kaplan is tryng to make right here . Kaplan prepare you to have the correct answer right on the exam , USMLE is not a " REAL LIFE PRACTICE EXAM " if it was , all IMGs attendings would pass it easily without even reading Kaplan or UW . It 's not our way , it 's USMLE way . Period ! There is no such thing as " definitly correct answer " , that means each choice would have something right about it . Ask anyone who already took CK , that 's why every body is saying that EXAM IS VAGUE . You would never be 100 % sure about the correct answer because all look alike . Every body knows that NSIM of DKA is fluids, no doubt about that and you have to add K even if the level is normal as you correct the metabolic acidosis with normal saline and insulin , the K+ will fall and the patient will be hypokalemic , but you just don ' t add K when the level is above the normal range in USMLE way . That is the take home message that Kaplan is trying to do . Like I said before , That is a practice test and the correct answer is B Whether people agree or not is IRRELEVANT and it 's up to every one to digest the information given here , Kaplan 's not gonna put a gun in your head to accept it Happy Studying Folks !
Readily admit this...
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| new_n_lost
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doc_clotaire wrote: Take another look in Barbara Davis Poster ! 5. Add potassium (K+) when pH > 7.1 and serum K+ known to be normal or low (may use 20 mEq/L KPO4 and 20 mEq/L KAc [or KCl]) . That 's the teaching point Kaplan is tryng to make right here . Kaplan prepare you to have the correct answer right on the exam , USMLE is not a " REAL LIFE PRACTICE EXAM " if it was , all IMGs attendings would pass it easily without even reading Kaplan or UW . It 's not our way , it 's USMLE way . Period ! There is no such thing as " definitly correct answer " , that means each choice would have something right about it . Ask anyone who already took CK , that 's why every body is saying that EXAM IS VAGUE . You would never be 100 % sure about the correct answer because all look alike . Every body knows that NSIM of DKA is fluids, no doubt about that and you have to add K even if the level is normal as you correct the metabolic acidosis with normal saline and insulin , the K+ will fall and the patient will be hypokalemic , but you just don ' t add K when the level is above the normal range in USMLE way . That is the take home message that Kaplan is trying to do . Like I said before , That is a practice test and the correct answer is B Whether people agree or not is IRRELEVANT and it 's up to every one to digest the information given here , Kaplan 's not gonna put a gun in your head to accept it Happy Studying Folks !
Nice Way of Saying it 
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