insulic shock vs ketoacidosis

[SuperSaiyan3]

I'm wondering how you would be able to distinguish between the two if you walked in and saw someone passed out.

I can tell the treatment will be different, but they seem to both have similar symptoms...

- pallor
- rapid heart rate

Other than using glucose meters or blood chemistry analyzers, how would you be able to tell?

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[novawildcat]

Kassmaul (sp?) type breathing with an odor of acetone is highly indicative of ketoacidosis. Someone with ketoacidosis will also have lost a lot of fluid.

 

[IMDoc607]

....

 

[spicedmanna]

Patients with DKA can present with sweet-smelling ("fruity") breath from the ketones, marked tachypnea, in order to compensate for the metabolic acidosis, and clinical signs of dehydration. Often you'll also find diffuse abdominal pain, N/V, polyuria, and polydipsia, but these are hard to assess in the unconscious patient.

 

[spicedmanna]

What does this have to do with the MCAT, BTW? Unless things have changed, I don't think you will ever be asked to distinguish between the two on the MCAT. My recollection is that the exam isn't designed to test your knowledge of clinical medicine, but of the basic pre-medical prerequisites. This forum isn't really designed for homework help.

 

[novawildcat]

Actually you have to be careful with dka, it can be tricky. Insulin stimulates the na-k pump, thus in a state of low insulin, entry of potassium into cells is impaired. While total body potassium levels are low, plasma levels of potassium are actually high and may actually lead to complications similar to that of hyperkalemia-abdominal pain, weakness, tachycardia.

 

[IMDoc607]

Actually you have to be careful with dka, it can be tricky. Insulin stimulates the na-k pump, thus in a state of low insulin, entry of potassium into cells is impaired. While total body potassium levels are low, plasma levels of potassium are actually high and may actually lead to complications similar to that of hyperkalemia-abdominal pain, weakness, tachycardia.

....

 

[novawildcat]

I should of clarified that for the OP so thank you for filling in the gaps. Where do you go to school?

Ha I'm just a nontrad still trying to get in. I just have work experience as a chemist and have written a small biochemistry review on dka.

 

[IMDoc607]

Ha I'm just a nontrad still trying to get in. I just have work experience as a chemist and have written a small biochemistry review on dka.

Thanks for teaching me something

 

[group_theory]

Give them an IV bolus of regular insulin (10-15 U) followed by a 0.1gtt inslin drip . Usual fluid deficit is 3-5 L and then proceed to replace their sodium and fluid deficit within 24 hours. ;Once you reach a glucose of 250 you switch them to D5W to prevent hypoglycemia. As stated about try to keep their K in the normal range to prevent complications of hypokalemia. KCl with 40mEq/hour or more depending on how bad it is. Then monitor....ok I have had enough using my brain I know I missed some stuff but for you thats more than you'll ever need to know until you are a 4th year/resident.

I've admitted and managed a lot of DKAs. To be honest, if I found a known diabetic unconscious, I would not know if the patient would be hypoglycemic, or in some sort of hyperglycemic state (either DKA or hyperosmolar nonketotic state). I've yet to detect that "fruity smell" that everyone in this thread is talking about. Well, maybe once. I usually rely on physical exam findings, the patient's story, and lab findings.

As for the management of DKA - please don't use this thread or this post since there are subtle nuances of DKA management that can affect patient care. There's also subtle differences on management between adult and pediatric DKA.

Bolusing 10-15 units of regular insulin (as suggested above) has fallen out of favor and shouldn't really be done. The insulin drip should be 0.05 -0.1 unit/kg/hr with a reasonable rate, not just 0.1gtt as written above. When you're the ordering physician, it's important that you have your units of measurements and rates right. Also, you'll have a hard time getting KCl running at 40mEq/hr unless you have two central lines (or four peripheral lines) in the patients. Again those pesky units (I think you meant for 40mEq/L at whatever rate you choose but that's still a lot of potassium).

But please don't use SDN or this thread to learn how to diagnose or manage DKA.

 

[IMDoc607]

I've admitted and managed a lot of DKAs. To be honest, if I found a known diabetic unconscious, I would not know if the patient would be hypoglycemic, or in some sort of hyperglycemic state (either DKA or hyperosmolar nonketotic state). I've yet to detect that "fruity smell" that everyone in this thread is talking about. Well, maybe once. I usually rely on physical exam findings, the patient's story, and lab findings.

As for the management of DKA - please don't use this thread or this post since there are subtle nuances of DKA management that can affect patient care. There's also subtle differences on management between adult and pediatric DKA.

Bolusing 10-15 units of regular insulin (as suggested above) has fallen out of favor and shouldn't really be done. The insulin drip should be 0.05 -0.1 unit/kg/hr, not just 0.1gtt as written. When you're the ordering physician, it's important that you have your units of measurements and rates right. Also, you'll have a hard time getting KCl running at 40mEq/hr unless you have two central lines (or four peripheral lines) in the patients. Again those pesky units (I think you meant for 40mEq/L at whatever rate you choose but that's still a lot of potassium).

But please don't use SDN or this thread to learn how to diagnose or manage DKA.

Ok sorry...changed

 

[IMDoc607]

I've admitted and managed a lot of DKAs. To be honest, if I found a known diabetic unconscious, I would not know if the patient would be hypoglycemic, or in some sort of hyperglycemic state (either DKA or hyperosmolar nonketotic state). I've yet to detect that "fruity smell" that everyone in this thread is talking about. Well, maybe once. I usually rely on physical exam findings, the patient's story, and lab findings.

As for the management of DKA - please don't use this thread or this post since there are subtle nuances of DKA management that can affect patient care. There's also subtle differences on management between adult and pediatric DKA.

Bolusing 10-15 units of regular insulin (as suggested above) has fallen out of favor and shouldn't really be done. The insulin drip should be 0.05 -0.1 unit/kg/hr with a reasonable rate, not just 0.1gtt as written above. When you're the ordering physician, it's important that you have your units of measurements and rates right. Also, you'll have a hard time getting KCl running at 40mEq/hr unless you have two central lines (or four peripheral lines) in the patients. Again those pesky units (I think you meant for 40mEq/L at whatever rate you choose but that's still a lot of potassium).

But please don't use SDN or this thread to learn how to diagnose or manage DKA.

In fact, that is what I meant. I have a quick question for you. Do you find Harrison's is out dated? I have the 16 edition, but I read it sometimes wondering if I am reading old material.

Thanks

 

[SuperSaiyan3]

I won't.

Thanks for all the input guys. I only understood up to half the stuff (until it got super complex with units like gtt and what not) but it was really helpful.

In regards to the mcat, they SAY you don't need to know this stuff but from my experience it seems to always come up as a problem solving passage in the BS or PS in one way or another... it's better to overprepare than to underprepare.

Thanks a lot. You guys are on the ball.

 

[novawildcat]

Thanks for teaching me something

Yeah no problem. You are actually learning from one of the best, I had one of the first doctors who ever used IV insulin therapy in this country critique my article for me before I sent it in for peer review. He's an old timer, 85 years old, still practices, and is still sharp as anything. He gave me some good pointers. But yeah, patient history is most critical too. This thread is just for general info.

 

[spicedmanna]

In regards to the mcat, they SAY you don't need to know this stuff but from my experience it seems to always come up as a problem solving passage in the BS or PS in one way or another... it's better to overprepare than to underprepare

Well, from my experience with actually taking the MCAT, which was several years ago, you didn't really need to know anything clinical to solve the problems. You needed to have a solid understanding of the very basic concepts associated with the premedical prerequisites, good problem solving skills (lots of practice), and decent speed. That, in my experience, is what is going to give you the most bang for your buck. The MCAT will often wrap the relatively simple (meaning basic), critical (for answering the questions) concepts or information needed into complex-sounding or unfamiliar scenarios. It might seem like you need to know that peripheral stuff, but in reality, you just need to have the ability to rapidly assess what's important and what is crap very quickly and have a firm understanding of the basic concepts. For example, you may get a passage about DKA, but it won't ask you to diagnose or treat it. Instead, it might ask questions about acid-base physiology (or chemistry), sodium-potassium (or potassium-hydrogen ion) pump, principles of osmolarity, ketones, sugars, insulin (or other aspects of the endocrine system), different aspects of metabolism, etc. The clinical-sounding passage functions as a jumping off point. The MCAT won't focus on the clinical, because you need medical school for that. Otherwise, it would be more appropriate for the USMLE, not the MCAT (unless the MCAT has changed from when I took it).

While I do agree that it might be helpful to know more, beyond the basics, make sure you understand the basics and focus on what the question is really asking or looking for first and foremost. It's usually something fundamental. Don't get distracted by the wrapper.

 

[Isoprop]

unless the mcat has changed since I last took it THIS YEAR, everything spicedmanna said is absolutely true.

you don't have to understand the passage to answer all the questions correctly.

 

[ksmi117]

SDN is not for homework help. Closing.