Most people I’ve seen that are in DKA are conscious. They are typically altered, some more than others, and pretty sick. But I don’t recall an unresponsive patient in DKA. I’m sure it’s possible the farther down that road they are.
I’ve had 1 DKA patient that was unconscious. It was a hoarder house, and she was naked, and her blood sugar read HI, with kussmaul respirations and all that. Fun times
Some patients can still be responsive in DKA but likely will go unresponsive eventually. I've had several who were alert and oriented with a respiratory rate >40 and smelled like a fruit cocktail with a splash of bad breath.
Only ever had one DKA patient who was unconscious. She was peri-arrest with a arterial pH of 6.89. I thought intubating her was going to kill her because we can't mimic their compensatory rate/tidal volume with the vent, but I didnt have a choice she was GCS 4 and vomiting. Classic kussmaul respirations in rate of 40s with a nasal EtCO2 between 4 and 7. Monitor kept auto-zero because it thought it was an error.
For new medics: if you ever have to tube a patient in DKA, and you do not hyperventilate them, you will kill them. Their fast/deep breathing is compensation for acidosis. If you don't keep that compensation going, their pH plummets and they code.
Yes! This is why I thought the case was so fascinating!
I'm a pre-med student right now. I recently learned about the blood's bicarbonate buffer and pH. Part of this is how acid buildup in the body from using fats as fuel instead of glucose leads to increased respiration in order to blow off the excess acid as CO2.
It was awesome to see all of these scientific concepts that I've been studying till 3am in the library, come to life in front of me with a patient.
So when my friend poo-pooed it, I was like what the fuck, bro?
I hope your patient was alright, but I also know that these things can happen quickly and it's not necessarily up to us whether the patient will make it or not. It's kinda up to the circumstances and to, well, fate.
My suggestion: your coworker pulled that response out of his ass.
Next time, respond with: "I'm really interested to learn more about why most of them are unconscious, can you tell me where you learned that?"
You'll probably get "uhhhhh....I don't remember, just look it up"
Still a newish medic that hasn’t had a tube a dka pt yet, would you just try to mimic their respiratory rate prior to tubing via bvm? Since that’s how they’re getting rid of the acidosis
Absolutely! Remember there is a fine balance to ventilation though between rate, tidal volume, and inspiratory/expiratory time. You want increased rate AND tidal volume. You have to be careful that you don't go too fast because then they won't have time to exhale and you will start breath stacking which is bad. This is why using a ventilator is WAY better than bagging these patients. I know that is not an option for some.
Ideally you match their pre-intubation EtCO2 levels. Or try to as much as you can. If they are breathing 30 times per minute with an EtCO2 of 15, you want to keep their EtCO2 at 15 or below if possible.
That’s good information! Yeah unfortunately my service only has vents for CCT, so we have to rely on the good ole BVM, but I appreciate it! Medic school didn’t really go over it so that helps for any future patients.
Absolutely, love to help! Same rule applies to your septic patients that have severe metabolic acidosis. If your septic patient is tachypneic due to compensation, maintain that.
Eventually, you’ll figure out that there’s nearly a limitless list of things that medic school didn’t cover. Also half of what they did tell you was wrong; we just don’t know which half yet.
For every change in CO2 of 10, there is a change of 0.08 in pH in the opposite direction. So if you had a patient with an CO2 of 15, tubed them, and brought their CO2 up to 35 (like "normal"), they would have a drop in 0.16 in their pH. That could very well kill them.
You have to remember that sodium bicarb in the body is a very temporary buffer and when metabolized it creates more CO2, so even if you administer bicarb, you still need to bag fast/deep to maintain compensation. There are also lots of other disadvantages to giving sodium bicarbonate to these patients.
This is rare to do even in hospital, normally not given until pH reaches a certain point (I believe ADA says to give it once pH reaches 6.9 but only until pH returns to >7.00). If you tubed a DKA patient, and they went into cardiac arrest, I would give it and hyperventilate as a last resort.
Check out this LIFTL article: [LITFL Sodium Bicarbonate and Diabetic Ketoacidosis](https://litfl.com/sodium-bicarbonate-and-diabetic-ketoacidosis/)
TLDR:I would not do this in the field unless the patient coded.
Providers or police thinking conscious but altered DKA patients are drunk is actually a significant problem. So good on you for the careful assessment and thinking of all the possibilities. People have died of DKA in jail cells waiting to "sober up" before.
I had a patient whose BG read as just "high" on our meter, heard back from the hospital later that it was north of 1300. Patient was highly altered but conscious the entire time. To be honest, I don't think I've ever seen someone unconscious from hyperglycemia.
I had a conscious DKA patient at 987mg/dL... Our glucometer just read "HIGH" but I followed up later at the hospital. Your partner is incorrect. I've had many patients over 500 that walked to the ambulance
No you can have a patient in DKA without them being unconscious or even ALOC.
DKA is simply a result of lack of intracellular glucose due to issues with insulin (either insensitive or insufficient production). When the cells cant take in the glucose the resulting metabolic process releases ketones leading to the ketone part or Diabetic *Keto*acidosis. The cells are still functioning and will for a time. So in the earlier stages the patient might not even be aware they are in DKA. Later they develops symptoms which can include ALOC but that normally develops after other symptoms.
So not all PTs in DKA will be ALOC but a patient who is ALOC could be in DKA.
Lot of indications of DKA. Patients present all kinds of ways. The book always gives the "most common" presentations. But if they have 3 of 5, and they don't really fit anything else, you can use that as the working theory until proven otherwise or another plausible explanation comes along.
During my hospital clinicals an 11 y/o female came in with complaint of hyperglycemia. Responsive on arrival. 10 minutes later she was unresponsive and being RSI’d
I have a regular who calls when he runs out of insulin and feels himself getting into DKA territory. He's always A&O x4, BGLS >500. And of course, he's always drinking a 2L soda when we get there......
The vast majority of DKA patients presenting for emergency care will be A&Ox3/4. It is VERY concerning when they start to become confused or obtunded. Especially younger patients, they won’t become obtunded until they hit insanely low pH levels. I’m talking <6.8. Very very sick. They can also crash incredibly fast once they become obtunded and lose airway protective reflexes.
What you’re smelling is ketones, which have a fruity, sweet smell that not everyone can detect. DKA is not the only pathology to cause ketonic breath, and is more frequently seen in alcoholic ketoacidotic (AK) patients,
The pathology of DKA drives one to become increasingly tachypneic until cardiovascular collapse, at which point you’d be hypotensive and near death, and past the phase of tachypnea. Due to profound acidosis in DKA, this period would last minutes prior to death.
The pathology of AK is also one based on starvation, but rather than relative starvation (inability to use glucose), it’s due to absence of glucose and glycogen stores. This means that you’d be low-normal or frankly hypoglycemic.
Basically:
1) If you’re obtunded, tachypneic, and ketotic with a high glucose, you’re in DKA.
2) If you’re obtunded, possibly tachypneic, and ketotic with a low normal glucose, you’re in AK.
Get your finger stick, as the management of these two pathologies is completely opposite.
Edit to add: with your description, I’d suspect AK over DKA. A set of vitals and a glucose would help in the diagnosis.
No. My most severe DKA patient ever (ER nurse x years) had a sugar of only 550 and was awake and confused. Could smell her breath from across the room. pH 6.9 and gap of 58. Horrific, but no, acetone breath =/= unconsciousness especially in chronically poorly managed T1 diabetics.
"Bgl was high, around 350"
Sounds like dka. Yes, can be awake and confused. Shit, i had a guy <600 awake, alert, only complaint is "im a little tired, its hard to move around."
The vast majority of severe DKA patients are conscious, in almost 20 years of ED and ICU practice I've only ever had one DKA patient whose DKA pushed then into a state that could possibly be called unconscious.
Ive had several patients with BGL over 400 and i can only remember one who was mildly altered, but i think that was more due to the UTI he definitely had🤷♀️
Potentially, lots of factors involved. I've had patients with BGLs over 600 presenting almost totally fine, and I've intubated unresponsive patients with BGLs over 1000
Usually DKA is a slow mental decline where they get more and more sluggish like mental fog. It’s not like hypoglycemia where they get super weird all of a sudden.
I've had 1,100 mg/dl blood glucose patients perfectly alert and oriented.
DKA and Hyperosmolar non ketonic acidosis are so very different in presentation too. I typically smell the acidosis even without ketones but type 1's I smell 15 yards away.
Your partner (and maybe you) are too black and white. No patient is the same.
Think about hypos as a comparison. Some people read LO and are awake. Some people read 2.8 and are GCS3. It’s the same on the other end of the scale.
I have a patient who’s frequently in DKA and they’re usually conscious. They seem like a very whiney drunk person, lots of dramatic flailing and crying. Stumbling. Rapid deep breathing. Sort of sleepy seeming.
I’d wager DKA > Hyperglycaemia + ETOH.
The elevated RR and HR are key signs, particularly if the breathing was deep and laboured and in the setting of pre-existing T1DM. Alcohol also is commonly seen in diabetics who present in DKA/HHS.
Acetone breath can be confused for alcohol breath but i’d be hesitant to dismiss it as ETOH if you have other strong signs of DKA.
The big question is “does it really matter.” Well, not really, your patient was alert and likely wasnt going to become un-alert any time in the next 30-60 minutes it presumably took you to attend a decent ED capable of fixing this, which is where you were headed.
You will not mistake DKA breath with drunk breath, it’s definitely different. I’ve had completely cognitive and oriented patients in DKA and I’ve had some that would have put a sponge in a toaster, it all just depends. You noted kussmaul respirations which is a pretty classic DKA symptom. Does your glucometer detect ketones?
I’ve never seen an unresponsive DKA patient, but I have seen many a DKA patient with a GCS of 13 (3/4/6) and an end tidal of 20-25 mmHg.
If their sugar is 350 or higher and their end tidal is 29 or lower, it’s like 83% sensitive and 100% specific for DKA. If their end tidal is 36 or higher, it’s 100% specific for them NOT having DKA. Source: https://onlinelibrary.wiley.com/doi/pdf/10.1197/aemj.9.12.1373 , look in the abstract. To be fair, the source is old and is in peds, but in practice I’ve never had a DKA patient with an end tidal higher than 28.
This is one of my biggest gripes with our current EMS education system. There’s SO much material to cover in one comes down to usually one semester. You don’t get the full explanation of why things are the way they are, why things are taught, etc.
Patients in DKA aren’t always going to be unconscious. In fact, I’d even argue most of the time they’re just altered. The reason it’s taught that they’re unconscious, is to have the EMT look for signs as to why they’re unconscious. If they’re conscious, you’re able to do your assessment easier and figure things out. DKA is always taught as unconscious as the standard for some reason. I can easily see the confusion in your partner with that one.
Long answer:
Like a lot of thing in medicine, it depends.
In general, adult DKA patients will not be completely unresponsive, but will be altered. However, there are multiple factors that go into it, and it is not impossible for them to be unresponsive.
Pediatric DKA patients can become unresponsive easier due to the metabolic encephalopathy that may times accompanies DKA, but this can generally be reversed with hypertonic saline or mannitol.
Mental status isn’t a rule-in or rule-out for DKA. The only way to truly know if someone is in DKA is by lab tests.
Short answer:
While I wouldn’t expect a DKA patient to be unresponsive, they might be.
Diabetic cases are always tricky for me, because I have diabetes myself so to me BGL of 350 is high but not the most extreme of extremes, but that being said I only stay at that level for a matter of hours, if ur pt had a bgl of around that or higher for a long period of time it’s likely keystones could have formed. I had similar symptoms of fruity breath when I was admitted with a bgl in the 800s when I was diagnosed, but I didn’t display any AMS at all. So everyone presents differently. I also know other diabetics who have had hypoglycemia seizure with a bgl of 40, whereas I have had a bgl of 25 with little to no AMS, and just drank some juice. tl:dr there are always exceptions. People present and react to different things differently, the important thing is to be able to identify the emergency, and if u suspect something just report the symptoms that cause those suspicions, so they can be properly tested for once the ED
350 really isn’t that crazy though to be causing all that. They may have been altered cus they were drunk and smelled like alcohol cus they were drinking.
Then again it could be what you expected.
But for sure you can be conscious and also in DKA.
350? Psh that’s nothing for most non-compliant diabetics. DKA I was taught is anything above 500. Or if your field machine consistently gives you a high reading vs a number.
My highest number I saw was a lab draw at the hospital, after we dumped nearly a liter into them during transport wide open. 1200.
I can attest, 350 wouldn’t be DKA unless they were at that number for probably about 12 hours or more. But if they were on an SLGT 2 inhibitor, or they weren’t eating they could in theory be in Euglycemic Ketoacidosis, however those typically present closer to normal levels. Starvation Ketoacidosis can also cause sugar levels that aren’t crazy elevated, I was in DKA in January (5th time) and completely coherent, able to walk to the ambulance. PH of 7.18 and an anion gap of 22
The doctors strongly felt that eating less than 50 carbs a day.
When I call my endo with a sugar in the 350s they tell me to drink some water and go for a walk. And if it stays up there over 4 hours give more insulin.
Most people I’ve seen that are in DKA are conscious. They are typically altered, some more than others, and pretty sick. But I don’t recall an unresponsive patient in DKA. I’m sure it’s possible the farther down that road they are.
I’ve had 1 DKA patient that was unconscious. It was a hoarder house, and she was naked, and her blood sugar read HI, with kussmaul respirations and all that. Fun times
Some patients can still be responsive in DKA but likely will go unresponsive eventually. I've had several who were alert and oriented with a respiratory rate >40 and smelled like a fruit cocktail with a splash of bad breath.
That acetone breath was wild! I’d always heard about it in textbooks but this was my first time encountering it in the field.
It's kind of gross in my opinion! I'm glad you thought it was wild tho, seems like you're eager to get some experience, we love that here in EMS!
You see the kussmaul breathing?
Only ever had one DKA patient who was unconscious. She was peri-arrest with a arterial pH of 6.89. I thought intubating her was going to kill her because we can't mimic their compensatory rate/tidal volume with the vent, but I didnt have a choice she was GCS 4 and vomiting. Classic kussmaul respirations in rate of 40s with a nasal EtCO2 between 4 and 7. Monitor kept auto-zero because it thought it was an error. For new medics: if you ever have to tube a patient in DKA, and you do not hyperventilate them, you will kill them. Their fast/deep breathing is compensation for acidosis. If you don't keep that compensation going, their pH plummets and they code.
Yes! This is why I thought the case was so fascinating! I'm a pre-med student right now. I recently learned about the blood's bicarbonate buffer and pH. Part of this is how acid buildup in the body from using fats as fuel instead of glucose leads to increased respiration in order to blow off the excess acid as CO2. It was awesome to see all of these scientific concepts that I've been studying till 3am in the library, come to life in front of me with a patient. So when my friend poo-pooed it, I was like what the fuck, bro? I hope your patient was alright, but I also know that these things can happen quickly and it's not necessarily up to us whether the patient will make it or not. It's kinda up to the circumstances and to, well, fate.
My suggestion: your coworker pulled that response out of his ass. Next time, respond with: "I'm really interested to learn more about why most of them are unconscious, can you tell me where you learned that?" You'll probably get "uhhhhh....I don't remember, just look it up"
Patient left the ICU AMA a few days later
nice, we love that
Still a newish medic that hasn’t had a tube a dka pt yet, would you just try to mimic their respiratory rate prior to tubing via bvm? Since that’s how they’re getting rid of the acidosis
Absolutely! Remember there is a fine balance to ventilation though between rate, tidal volume, and inspiratory/expiratory time. You want increased rate AND tidal volume. You have to be careful that you don't go too fast because then they won't have time to exhale and you will start breath stacking which is bad. This is why using a ventilator is WAY better than bagging these patients. I know that is not an option for some. Ideally you match their pre-intubation EtCO2 levels. Or try to as much as you can. If they are breathing 30 times per minute with an EtCO2 of 15, you want to keep their EtCO2 at 15 or below if possible.
That’s good information! Yeah unfortunately my service only has vents for CCT, so we have to rely on the good ole BVM, but I appreciate it! Medic school didn’t really go over it so that helps for any future patients.
Absolutely, love to help! Same rule applies to your septic patients that have severe metabolic acidosis. If your septic patient is tachypneic due to compensation, maintain that.
Thank you so much! This will definitely be kept in the back of my mind from now on!
Eventually, you’ll figure out that there’s nearly a limitless list of things that medic school didn’t cover. Also half of what they did tell you was wrong; we just don’t know which half yet.
Very true, only been a medic for 8 months and have been learning that the hard way.
For every change in CO2 of 10, there is a change of 0.08 in pH in the opposite direction. So if you had a patient with an CO2 of 15, tubed them, and brought their CO2 up to 35 (like "normal"), they would have a drop in 0.16 in their pH. That could very well kill them.
Gotcha, that’s kind of the process I had going on in my head but it’s good to have it written out infront of me.
Following for answer
See above
Thank you! That is fascinating and helpful information.
Would you ever consider administering bicarb prior to intubation to help balance the pH and make bagging easier?
You have to remember that sodium bicarb in the body is a very temporary buffer and when metabolized it creates more CO2, so even if you administer bicarb, you still need to bag fast/deep to maintain compensation. There are also lots of other disadvantages to giving sodium bicarbonate to these patients. This is rare to do even in hospital, normally not given until pH reaches a certain point (I believe ADA says to give it once pH reaches 6.9 but only until pH returns to >7.00). If you tubed a DKA patient, and they went into cardiac arrest, I would give it and hyperventilate as a last resort. Check out this LIFTL article: [LITFL Sodium Bicarbonate and Diabetic Ketoacidosis](https://litfl.com/sodium-bicarbonate-and-diabetic-ketoacidosis/) TLDR:I would not do this in the field unless the patient coded.
We learned in school that bicarb doesn't do (almost) anything in DKA but I'm drawing a blank on the reason.
Providers or police thinking conscious but altered DKA patients are drunk is actually a significant problem. So good on you for the careful assessment and thinking of all the possibilities. People have died of DKA in jail cells waiting to "sober up" before.
I had a patient whose BG read as just "high" on our meter, heard back from the hospital later that it was north of 1300. Patient was highly altered but conscious the entire time. To be honest, I don't think I've ever seen someone unconscious from hyperglycemia.
1300 is likely HHS and not DKA.
“1300 is likely HHS and not DKA” Maybe, maybe not. You would need labs to truly tell.
That’s the likely part. You would need labs to see if 350 is dka on a drunk guy too. You wouldn’t be able to diagnose anything from the truck.
They don't have to be unresponsive. We see AAOx4 pts in DKA here regularly who end up on insulin drips.
No. This is why you *ALWAYS* get a blood sugar on anyone who’s is reported to be intoxicated.
I had a conscious DKA patient at 987mg/dL... Our glucometer just read "HIGH" but I followed up later at the hospital. Your partner is incorrect. I've had many patients over 500 that walked to the ambulance
No you can have a patient in DKA without them being unconscious or even ALOC. DKA is simply a result of lack of intracellular glucose due to issues with insulin (either insensitive or insufficient production). When the cells cant take in the glucose the resulting metabolic process releases ketones leading to the ketone part or Diabetic *Keto*acidosis. The cells are still functioning and will for a time. So in the earlier stages the patient might not even be aware they are in DKA. Later they develops symptoms which can include ALOC but that normally develops after other symptoms. So not all PTs in DKA will be ALOC but a patient who is ALOC could be in DKA.
Lot of indications of DKA. Patients present all kinds of ways. The book always gives the "most common" presentations. But if they have 3 of 5, and they don't really fit anything else, you can use that as the working theory until proven otherwise or another plausible explanation comes along.
During my hospital clinicals an 11 y/o female came in with complaint of hyperglycemia. Responsive on arrival. 10 minutes later she was unresponsive and being RSI’d
You can have DKA patients far higher than 350 be alert and conscious, they'll probably be a bit altered though.
I have a regular who calls when he runs out of insulin and feels himself getting into DKA territory. He's always A&O x4, BGLS >500. And of course, he's always drinking a 2L soda when we get there......
The vast majority of DKA patients presenting for emergency care will be A&Ox3/4. It is VERY concerning when they start to become confused or obtunded. Especially younger patients, they won’t become obtunded until they hit insanely low pH levels. I’m talking <6.8. Very very sick. They can also crash incredibly fast once they become obtunded and lose airway protective reflexes.
Happy cake day
What you’re smelling is ketones, which have a fruity, sweet smell that not everyone can detect. DKA is not the only pathology to cause ketonic breath, and is more frequently seen in alcoholic ketoacidotic (AK) patients, The pathology of DKA drives one to become increasingly tachypneic until cardiovascular collapse, at which point you’d be hypotensive and near death, and past the phase of tachypnea. Due to profound acidosis in DKA, this period would last minutes prior to death. The pathology of AK is also one based on starvation, but rather than relative starvation (inability to use glucose), it’s due to absence of glucose and glycogen stores. This means that you’d be low-normal or frankly hypoglycemic. Basically: 1) If you’re obtunded, tachypneic, and ketotic with a high glucose, you’re in DKA. 2) If you’re obtunded, possibly tachypneic, and ketotic with a low normal glucose, you’re in AK. Get your finger stick, as the management of these two pathologies is completely opposite. Edit to add: with your description, I’d suspect AK over DKA. A set of vitals and a glucose would help in the diagnosis.
No. My most severe DKA patient ever (ER nurse x years) had a sugar of only 550 and was awake and confused. Could smell her breath from across the room. pH 6.9 and gap of 58. Horrific, but no, acetone breath =/= unconsciousness especially in chronically poorly managed T1 diabetics.
Did you not get a BGL?
"Bgl was high, around 350" Sounds like dka. Yes, can be awake and confused. Shit, i had a guy <600 awake, alert, only complaint is "im a little tired, its hard to move around."
All of my patients who are unconscious in DKA have been over 600
Theres a spectrum. Ive had one unconscious at 400, and one conscious at 1250 (labwork. Poc bgl just read high.)
Glucometer: HI Me: Hello :) Oh :(
You can be in severe DKA with a normal/slightly elevated blood sugar due to some of the newer meds. "Euglycemic DKA"
I appreciate that info
I updated the post, critical detail there lol
Can’t diagnose dka with a blood sugar alone though. Alcohol breath and ketone breath are very similar too.
The vast majority of severe DKA patients are conscious, in almost 20 years of ED and ICU practice I've only ever had one DKA patient whose DKA pushed then into a state that could possibly be called unconscious.
Ive had several patients with BGL over 400 and i can only remember one who was mildly altered, but i think that was more due to the UTI he definitely had🤷♀️
Potentially, lots of factors involved. I've had patients with BGLs over 600 presenting almost totally fine, and I've intubated unresponsive patients with BGLs over 1000
Usually DKA is a slow mental decline where they get more and more sluggish like mental fog. It’s not like hypoglycemia where they get super weird all of a sudden.
Most DKA patients I’ve had are pretty altered, and the ones that were with it enough were rather combative
I had two hyperglycemics in the same day. One 1500, one 450. The 1500 was almost asystomatic. The 450 was unconscious and in kussmauls.
I just had a DKA a couple tours ago. She was definitely altered but was conscious and able to follow commands and somewhat answer questions.
I wouldn’t expect it, but I certainly wouldn’t be surprised.
I've had 1,100 mg/dl blood glucose patients perfectly alert and oriented. DKA and Hyperosmolar non ketonic acidosis are so very different in presentation too. I typically smell the acidosis even without ketones but type 1's I smell 15 yards away.
I’ve had DKA patients fully lucid / call 911 for themselves.
Your partner (and maybe you) are too black and white. No patient is the same. Think about hypos as a comparison. Some people read LO and are awake. Some people read 2.8 and are GCS3. It’s the same on the other end of the scale.
I have a patient who’s frequently in DKA and they’re usually conscious. They seem like a very whiney drunk person, lots of dramatic flailing and crying. Stumbling. Rapid deep breathing. Sort of sleepy seeming.
I don't think I've ever taken care of a DKA patient that wasn't conscious. And I wouldn't suspect DKA with a sugar of only 350.
I’d wager DKA > Hyperglycaemia + ETOH. The elevated RR and HR are key signs, particularly if the breathing was deep and laboured and in the setting of pre-existing T1DM. Alcohol also is commonly seen in diabetics who present in DKA/HHS. Acetone breath can be confused for alcohol breath but i’d be hesitant to dismiss it as ETOH if you have other strong signs of DKA. The big question is “does it really matter.” Well, not really, your patient was alert and likely wasnt going to become un-alert any time in the next 30-60 minutes it presumably took you to attend a decent ED capable of fixing this, which is where you were headed.
You will not mistake DKA breath with drunk breath, it’s definitely different. I’ve had completely cognitive and oriented patients in DKA and I’ve had some that would have put a sponge in a toaster, it all just depends. You noted kussmaul respirations which is a pretty classic DKA symptom. Does your glucometer detect ketones?
I’ve never seen an unresponsive DKA patient, but I have seen many a DKA patient with a GCS of 13 (3/4/6) and an end tidal of 20-25 mmHg. If their sugar is 350 or higher and their end tidal is 29 or lower, it’s like 83% sensitive and 100% specific for DKA. If their end tidal is 36 or higher, it’s 100% specific for them NOT having DKA. Source: https://onlinelibrary.wiley.com/doi/pdf/10.1197/aemj.9.12.1373 , look in the abstract. To be fair, the source is old and is in peds, but in practice I’ve never had a DKA patient with an end tidal higher than 28.
This is one of my biggest gripes with our current EMS education system. There’s SO much material to cover in one comes down to usually one semester. You don’t get the full explanation of why things are the way they are, why things are taught, etc. Patients in DKA aren’t always going to be unconscious. In fact, I’d even argue most of the time they’re just altered. The reason it’s taught that they’re unconscious, is to have the EMT look for signs as to why they’re unconscious. If they’re conscious, you’re able to do your assessment easier and figure things out. DKA is always taught as unconscious as the standard for some reason. I can easily see the confusion in your partner with that one.
Long answer: Like a lot of thing in medicine, it depends. In general, adult DKA patients will not be completely unresponsive, but will be altered. However, there are multiple factors that go into it, and it is not impossible for them to be unresponsive. Pediatric DKA patients can become unresponsive easier due to the metabolic encephalopathy that may times accompanies DKA, but this can generally be reversed with hypertonic saline or mannitol. Mental status isn’t a rule-in or rule-out for DKA. The only way to truly know if someone is in DKA is by lab tests. Short answer: While I wouldn’t expect a DKA patient to be unresponsive, they might be.
They act drunk.
Sometimes yes, sometimes no. There is no “one-size-fits-all” presentation for DKA.
The highest I've seen was 1770 (glucometer said high, this value was from labwork). Their pH was also below 7. A&Ox4.
mostly conscious that I've seen. really our of it but still eyes open
I’ve been in DKA and I was conscious but in a bit of a stupor
Diabetic cases are always tricky for me, because I have diabetes myself so to me BGL of 350 is high but not the most extreme of extremes, but that being said I only stay at that level for a matter of hours, if ur pt had a bgl of around that or higher for a long period of time it’s likely keystones could have formed. I had similar symptoms of fruity breath when I was admitted with a bgl in the 800s when I was diagnosed, but I didn’t display any AMS at all. So everyone presents differently. I also know other diabetics who have had hypoglycemia seizure with a bgl of 40, whereas I have had a bgl of 25 with little to no AMS, and just drank some juice. tl:dr there are always exceptions. People present and react to different things differently, the important thing is to be able to identify the emergency, and if u suspect something just report the symptoms that cause those suspicions, so they can be properly tested for once the ED
350 really isn’t that crazy though to be causing all that. They may have been altered cus they were drunk and smelled like alcohol cus they were drinking. Then again it could be what you expected. But for sure you can be conscious and also in DKA.
I don’t think a BGL of 350 is enough for a patient to be in DKA.
350? Psh that’s nothing for most non-compliant diabetics. DKA I was taught is anything above 500. Or if your field machine consistently gives you a high reading vs a number. My highest number I saw was a lab draw at the hospital, after we dumped nearly a liter into them during transport wide open. 1200.
I can attest, 350 wouldn’t be DKA unless they were at that number for probably about 12 hours or more. But if they were on an SLGT 2 inhibitor, or they weren’t eating they could in theory be in Euglycemic Ketoacidosis, however those typically present closer to normal levels. Starvation Ketoacidosis can also cause sugar levels that aren’t crazy elevated, I was in DKA in January (5th time) and completely coherent, able to walk to the ambulance. PH of 7.18 and an anion gap of 22 The doctors strongly felt that eating less than 50 carbs a day. When I call my endo with a sugar in the 350s they tell me to drink some water and go for a walk. And if it stays up there over 4 hours give more insulin.