“Once I started taking care of my kid with diabetes at home, it made me realize, ‘Gee, I’m doing a lot of stupid stuff in the emergency department with these folks,’” she said. “I’m doing a lot of stuff I don’t need to do and I’m probably not doing some stuff I really need to do.”
To help others find their epiphany, Dr. Aubin and Camiron Pfennig, MD, MHPE, an emergency physician with Greenville Health System and associate professor at the University of South Carolina in Greenville, presented, “DKA and Hyperosmolar Syndrome—High-Yield Pearls and Pitfalls” at ACEP15 on Wednesday.
First, Dr. Aubin suggested that emergency physicians not prejudge treatment based on dated stereotypes of diabetic patients.
“Diabetes is a spectrum,” she said. “There’s fat people with Type 1 diabetes. There are skinny people that get adult-onset Type 1 diabetes. There are little kids that are fat that have Type 2 diabetes. And all of them can go into ketosis and you don’t really know.”
The session’s pearls included highlighting that moderate asymptomatic hyperglycemia is not an emergency, that urging physicians to administer rapid-acting insulin if they feel like they need to reduce glucose levels in the ED, and that reminding doctors that mild DKA can be treated with subcutaneous insulin. Pitfalls included failure to check potassium levels before initiating insulin, failure to start glucose and continue insulin when sugar levels decrease but acidosis continues, and failure to give subcutaneous insulin prior to stopping an insulin drop.
Dr. Aubin said that while it’s relatively standard to do a finger-stick check for diabetics’ glucose levels, patients that have long wait times for treatment should also get a ketone test if the glucose analysis shows elevated levels.
“If it’s high, do a finger stick ketone test because that’s going to allow you to sort out the sick versus not-so-sick diabetics,” she added.
Dr. Pfennig said that it’s important to focus on fluid management, electrolyte control, and potential insulin-drip initiation early on, as DKA and hyperosmolar syndrome are the most common life-threatening complications of diabetes in the United States. On the bright side, she said, one treatment option with no wrong answer is how to administer the insulin drip.
“One you’ve decided the patient is in DKA or hyperosmolar, and you’re to the insulin selection, we advocate one of two choices,” Dr. Pfennig said. “There really isn’t a wrong answer. You can bolus your insulin and then drip your insulin, or you can just drip your insulin. What I would advocate more than one versus the other is picking one and having your shop stick together.”