doc_clotaire
Forum Guru
Topics: 159
Posts: 1,240
|
PLEASE EXPLAIN !
A 53 year old woman presents to the emergency room with abdominal pain, nausea, vomiting, hypotensive, tachycardia and disoriented. A FSG check comes back as >500. You quickly get a urine sample and analyze it with a dipstick. It shows the following results:
Specific Gravity=1.005/pH=5.5/1+protein/4+glucose/+ketones/0 RBC,WBC, epithelials cells.
You promptly get IV access and draw the necessary blood studies. Your next step would be to:
a ) Give Normal saline bolus and run IV fluids wide open
b ) Give Normal saline and give 10 units of NPH and start an insulin drip at 0.1 units /kg /hr
c ) Give Normal saline and start on Diabeta 10 mg
d ) Give Normal saline , Wait for Lab result and give Insulin
___________________
The elevator to succes is broke ,you must take the stairs
|
| drgeorgie
Forum Senior
Topics: 22
Posts: 149
|
b? DKA management isn't it
___________________
"The army saw Goliath as too big to hit. David saw him as too big to miss!"
|
| hanialkhadher
Forum Elite
Topics: 16
Posts: 256
|
b ) Give Normal saline and give 10 units of NPH and start an insulin drip at 0.1 units /kg /hr
___________________
"أقرأ بأسم ربك الذي خلق,خلق الأنسان من علق,أقرأ و ربك الأكرم, الذي علم بالقلم,علم الأنسان ما لم يعلم"
|
| titly
Forum Elite
Topics: 17
Posts: 290
|
B
___________________
we spend our days waiting for the ideal path to appear in front of us, but, what we forget is paths are made by walking, not by waiting. keep walking................................
|
| neuroblastoma
Forum Guru
Topics: 99
Posts: 1,010
|
B
___________________
yahoo mesenger and skype ID asdvsd2003
|
| doc_clotaire
Forum Guru
Topics: 159
Posts: 1,240
|
Like Dr Fisher would say :
B is the most common WRONG answer the Board is looking for 
Please try again !
___________________
The elevator to succes is broke ,you must take the stairs
|
| hgheith
Forum Elite
Topics: 39
Posts: 266
|
What is FSG?
|
| doc_clotaire
Forum Guru
Topics: 159
Posts: 1,240
|
Fasting Serum Glucose
___________________
The elevator to succes is broke ,you must take the stairs
|
| Doc750
transfer:step 3 prison
Topics: 52
Posts: 636
|
D
___________________
Experience is a hard teacher because she gives the test first, and the lesson afterwards.
|
| mjl1717
Forum Hero
Topics: 955
Posts: 5,450
|
good q clotaire-- I like anser d.. wouldnt the urine sp. gravity be higher if the person was dehydrated
___________________
Smell the coffee! "Is That an Osler move??"
|
| doc_clotaire
Forum Guru
Topics: 159
Posts: 1,240
|
Can u please elaborate guys !
___________________
The elevator to succes is broke ,you must take the stairs
|
| Ivonne
Forum Guru
Topics: 51
Posts: 1,392
|
Ok. i will go with D: Normal saline (but not IV fuids "wide open" (A) because of risk of cerebral edema), wait for electrolytes, specially potasium and then insulin, because in severe hypokalemia administration of insuline without correcting the potasium can cause dysrhytmias(B).
___________________
If you beleive you can do it then you WILL DO IT!! (by Mymeghhi)
|
| mjl1717
Forum Hero
Topics: 955
Posts: 5,450
|
Ok clotaire--- I would not pick answer c because in ketoacidosis they are more aggressive in the E.R. and give insulin. Overall F.S. or blood work then regular insulin, F.S. or blood work then regular insulin with N.S running at maybe 80 ml/ per hour.. Once stable you could have the patient on a BID dose of novolog or novolin insulin with a sliding scale..also P.O. meds in a
disoriented person is bad medicine..
Edited by mjl1717 on 10/24/07 - 08:15 PM
___________________
Smell the coffee! "Is That an Osler move??"
|
| neuroblastoma
Forum Guru
Topics: 99
Posts: 1,010
|
good ivonne
___________________
yahoo mesenger and skype ID asdvsd2003
|
| hanialkhadher
Forum Elite
Topics: 16
Posts: 256
|
a ) Give Normal saline bolus and run IV fluids wide open
___________________
"أقرأ بأسم ربك الذي خلق,خلق الأنسان من علق,أقرأ و ربك الأكرم, الذي علم بالقلم,علم الأنسان ما لم يعلم"
|
| genbot
Forum Guru
Topics: 13
Posts: 545
|
Answer is D
But if this is diabetic ketoacidosis as the clinical presentation and the initial lab results would seem to suggest, the urine specific gravity is wrong. Its way too low
However considering this to be DKA u would definitely want to wait for potassium levels before administering insulin, although this is THE treatment for DKA.
One more thing that comes to mind with a low urine specific gravity and hypotension is Diabetes insipidus but FSG and urine exam argue against that.
Lastly abdominal pain, GI symptoms and hypotension could also make u think of adrenal crisis but those guys get hypoglycemia not hyperglycemia and obviously no ketones in urine.
But yes it would be prudent to treat this patient with IV fluids till the lab results confirm DKA and specific Insulin therapy could then be begun.
One more important thing with DKA is that although the fluid deficit is around 4-5 litres it needs to be corrected over 6-8 hours, more rapid correction can sometimes lead to cerebral edema.
you dont give NPH insulin for DKA, only give regular insulin.
and Obviously DKA is never to be treated with oral agents, so a big no to Diabeta as well
___________________
Step1 267/99. Step2 269/99. CS pass. ECFMG certified. Match 2009. MAY THE FORCE BE WITH ME (The one they call the strong nuclear force!)
|
| RitaM
Forum Newbie
Topics: 1
Posts: 61
|
This looks like more HONK i.e nonketotic acidosis.The best management in that case is to keep the fluids wide open and then check whether there is a need for Insulin.
|
| genbot
Forum Guru
Topics: 13
Posts: 545
|
This cannot be HONK.
They dont present with pain abdomen, vomiting etc. thats relatively specific for DKA.
Secondly they have much higher blood sugars and ketones would be absent from urine.
Too many pointers against HONK you see...
___________________
Step1 267/99. Step2 269/99. CS pass. ECFMG certified. Match 2009. MAY THE FORCE BE WITH ME (The one they call the strong nuclear force!)
|
| genbot
Forum Guru
Topics: 13
Posts: 545
|
The thing with insulin is that its only to be given at a specific dosage in DKA which is much higher than for any other condition, so u need to you confirm DKA first with further laboratory testing which includes blood gas analysis. Remember DKA is diabetic ketoACIDOSIS.
No laboratory test can tell u whether there is a need for insulin in HONK. There is fixed protocol for treatment in this condition which includes plenty of iv fluids and insulin, although insulin requirement is much lower than that in DKA.
So RitaM no laboratory testing determines the need for insulin in HONK, but yes they do help in differentiating it from DKA, which i mentioned before requires much higher doses of insulin
Edited by genbot on 10/25/07 - 10:41 PM
___________________
Step1 267/99. Step2 269/99. CS pass. ECFMG certified. Match 2009. MAY THE FORCE BE WITH ME (The one they call the strong nuclear force!)
|
| drgeorgie
Forum Senior
Topics: 22
Posts: 149
|
SO WHATS the answer?
in DKA do we wait for results?? other than a blood sugar value to give Insulin?
___________________
"The army saw Goliath as too big to hit. David saw him as too big to miss!"
|
| genbot
Forum Guru
Topics: 13
Posts: 545
|
Ya thats right drgeorgie..
___________________
Step1 267/99. Step2 269/99. CS pass. ECFMG certified. Match 2009. MAY THE FORCE BE WITH ME (The one they call the strong nuclear force!)
|
| genbot
Forum Guru
Topics: 13
Posts: 545
|
only because u need to confirm DKA first...it is not a diagnosis made purely on blood sugar values and clinical presentation. u need to document KETOACIDOSIS by laboratory methods and then start with specific insulin therapy, although iv fluids can be started earlier in view of patient's volume depletion
___________________
Step1 267/99. Step2 269/99. CS pass. ECFMG certified. Match 2009. MAY THE FORCE BE WITH ME (The one they call the strong nuclear force!)
|
| drgeorgie
Forum Senior
Topics: 22
Posts: 149
|
so the answer is A?
but this is my doubt...what has ketoacidosis got to do with insulin? See the bld sugar value of this patient is >500.... so whats the harm in starting insulin??
well A may be the best next step..because first step is volume repletion? esp the pt is in hypotension..but usually we start insulin drip on a different line..
but may be becoz the pt is hypotensive, we correct that first?
___________________
"The army saw Goliath as too big to hit. David saw him as too big to miss!"
|
| genbot
Forum Guru
Topics: 13
Posts: 545
|
No the answer is D
Sure u need to correct hypotension with normal saline but u dont need to rush it in as if the patient is in shock. Just enough to bring up the BP.
In view of the high suspicion of underlyin DKA too rapid fluid expansion can lead to cerebral edema.
Also DKA is an insulin deficient state, which after confirmation requires high doses of insulin.
Yes give NS by all means to correct hypotension but dont drown the patient with fluids, that aint recommended.
And when u confirm DKA make sure u start the right dose of insulin (not just any dose!)
Its pretty simple...
___________________
Step1 267/99. Step2 269/99. CS pass. ECFMG certified. Match 2009. MAY THE FORCE BE WITH ME (The one they call the strong nuclear force!)
|
| doyoudig
Forum Guru
Topics: 144
Posts: 613
|
a ) Give Normal saline bolus and run IV fluids wide open
|
|
| |
| | | | | | | | | | | | | | | | | | | | | | | | | |
