Pre-Hospital Assessment of Diabetes Ketoacidosis - Case Study Example

PRE-HOSPITAL ASSESSMENT OF DIABETES KETOACIDOSIS by Student’s Names Code+ Course Name Professor’s Name University/College name City, State Date Introduction Many accidents and medical emergencies happen that require immediate attention to save lives. These emergencies may occur in a non-hospital setup requiring patient(s) to be attended to urgently prior to hospital care. Prior-hospital care services are provided by emergency medical teams (EMTs) or paramedics (Ambulance Victoria 2014). A paramedic is a healthcare professional responsible for providing assistance and attending to any form of patient request upon any medical crisis (Australian Council of Paramedicine [ACP] 2008, p. 1). They perform health assessment and initial diagnosis in addition to creating a plan for treating or managing the patient’s medical condition. In some medical cases, paramedics can help patient recover from their illness without referring to another health institution or profession. In some other cases, they can only stabilize the patient before transferring to a health care center for further management and treatments (ACP 2008, p. 1). Healthcare workload demand sometimes overwhelms the available workforce. Despite this, emergency services cannot be compromised (Curtis, Ramsden & Lord 2012, p. 7). Emergency conditions such as diabetes ketoacidosis (DKA) require urgent care regardless of how far a health center is. Therefore, paramedics are assigned responsibility of providing pre-hospital emergency care to DKA patients. They are equipped with basic skills to facilitate medical assessment, diagnosis and management of DKA. Basic skills necessary for patient assessment includes history taking, physical examination and interpreting laboratory results related to DKA. The history must be taken in a comprehensive manner to allow selection of possible diagnosis; thus, paramedics should also possess good clinical assessment and excellent judgment skills. Diabetes Ketoacidosis (DKA) DKA is a severe form of complication in diabetic patients that requires urgent management and treatment. 51% of under 24 year-old's deaths in patients with type I diabetes mellitus (DM) are attributed to DKA (Espes et al.,2013, p. 130). Type II DM can also be clinically complicated by DKA under extreme physiological stressful conditions such as illness, trauma and surgery (Solleimapour et al. 2013, p. 591). DKA is characterized by dehydration, hyperglycemia and acidosis (Raghavan 2013). According to Espes et al. (2013), DKA is commonly precipitated by non-adherent to insulin treatment and concurrent infection. Insulin deficiency results in impaired carbohydrate utilization in tissues. Consequently, other energy sources such as fatty acids are metabolized causing the accumulation of acidic metabolites known as ketoacidosis with serum glucose and ketone levels elevated, and blood pH below 7.3 (Espes et al. 2013). Etiology and Precipitating Factors DKA is precipitated by various factors including infections, trauma and surgery which should be considered during assessment. DKA is also common in lack of exogenous insulin due to missed insulin treatment, concomitant infection, and in newly diagnosed diabetic patients. Other possible causes account for 20% of DKA scenarios (Rhaghavan 2013). In type 1 DM, causes of DKA include (1) acute deficiency of insulin in newly diagnosed patients, (2) poor adherence and compliance with the prescribed insulin doses or an omission of a dose due to a non-comprehensive patient education, loss of appetite, or financial difficulties to purchase insulin (Musey et al. 1995, pp. 485-486), (3) infections such as urinary, gastrointestinal and respiratory tract bacterial infections, or a concurrent illness, (4) emotional, surgical or medical stress, (5) brittle diabetes, (6) catheter blockage during insulin infusion, (7) idiopathic or unidentifiable cause and (8) insulin infusion pump mechanical error (Rhaghavan 2013). DKA is not very common in type II DM, but it is often precipitated by factors such as (1) co-morbidities with other diseases like pneumonia, myocardial infarction and prostatitis, and (2) drug interactions such as the use of pentamidine, corticosteroids, thiazides, tricyclic antidepressants and clozapine that cut down hypoglycemic effects of insulin (Impierrez, Murphy & Kitabchi 2002, p. 29). Pathophysiology DKA occurs when insulin levels are insufficient to meet metabolic needs (Sellers & Ludwig 2012, p. 8). Since insulin is responsible for promoting uptake and utilization of glucose in tissues, its deficiency depletes tissues of glucose causing stress that provokes release of counter regulatory stress hormones such as cortisol, epinephrine and growth hormone. These hormones and glucagon stimulate hepatic glycogenolysis, gluconeogenesis and lipolysis. Increased glycogenolysis, gluconeogenesis and decreased tissue glucose uptake leads to a severe hyperglycemic state. Blood glucose levels of about 235 mg/dl lead to excretion of glucose in urine, a process called glycosuria. Presence of excess glucose in urine drives movement of water from the renal tubular interstitium into the tubules via osmotic diuresis resulting in polyuria (Mistovich 2008). Loss of water through urine results in an increase of serum hyperosmolarity and viscosity. Consequently, more water is drawn from tissues, thereby exacerbating dehydration and causing polydipsia (Sellers & Ludwig 2012, p. 9). Lipolysis raises free fatty acid level in serum that are metabolized into acidic intermediates – ketoacids, and ketones such as beta-hydroxybutyrate (BHB) and acetone (Raghavan 2013). Metabolism of fatty acids occurs in hepatocyte mitochondria from acetyl coenzyme A. At first, progressive release of the acidic substances will result in controlled ketonemia. However, prolonged production of acidic metabolites will exceed intracellular and extracellular pH buffer capacity leading to a base deficit and an anion gap acidosis (Rhaghavan 2013). Uncontrolled ketonemia results in metabolic ketoacidosis and a decreased serum pH and bicarbonate ions. In an attempt to compensate for acidic conditions in the body, the respiratory system is stimulated resulting to a rapid but deep respirations referred to as Kussmaul respirations (Rhaghavan 2013). Some acetone is released during expiration producing the characteristic of ‘fruity’ odor (Mistovich 2008). Furthermore, the accumulating ketones soon exceed their incorporation and utilization in the Kreb's cycle (Rhaghavan 2013).Therefore, they end up getting excreted through urine, in a process called ketonuria. In addition, ketones, especially BHB may induce vomiting aggravating the already severe fluid deficiency and electrolyte loss (Mistovich 2008). Another problem experienced in DKA is electrolyte imbalance. Potassium ions are released in the plasma as a result of increased influx of hydrogen ion in an ion exchange process. This is due to increase ketoacid and base deficit and hyperkalemia is observed. However, total body potassium can be decreased due to loss in urine together with other electrolytes such as sodium and chloride ions through osmotic diuresis (Agabegi S & Agabegi E 2008, p. 189). Impaired consciousness level may occur if high osmolarity persists in the brain due to hyperglycemia and dehydration. Excessive dehydration may lead to hypovolemic shock and coma. Hyperglycemia may not be present in all DKA cases since euglycemic DKA have also been identified (Akbay et al. 2013, p. 134). Assessment of Patient with suspected DKA: History A comprehensive history is required for a paramedic to narrow down the differential diagnosis and choose a working final diagnosis (Center for Immediate Care Studies [SICS] 2013, p. 2). Since the time and place are limited in a pre-hospital set-up, patient assessment is a bit more challenging for a paramedic. Therefore, obtaining a thorough history and identifying significant clinical signs are valuable asset for a paramedic (SICS 2013, p. 2). Paramedics are usually alerted on a medical emergency. On arrival in the scene, patient’s history must be taken first. They then introduce themselves and enquire on patient’s condition. The response(s) (or no response) from the patient will provide salient information as to patient’s level of consciousness (Blaber & Harris 2011, p. 3). Presenting Complaint The chief presenting complaint(s) can be obtained from a conscious patient or from the patient’s guardian who knows the events that led to the complaint(s). In most cases, the patient will report feeling nauseous and having had episodes of vomiting and abdominal pain. These signs and symptoms are attributed to metabolic acidosis of DKA (Brazelton 2007, p. 2). History of Presenting Illness The onset of symptoms should be ascertained. DKA patients develop symptoms rapidly over less than 24 hour’s period (Umpierrez, Murphy & Kitabchi 2001, p. 29). Patients may convey good appetite and increased fluid intake in the last three days. The complaint may have been instigated by some trauma that should be documented as a precipitating factor for DKA. Knowledge on whether the patient is taking any medication for the suspected condition, that is, DKA or DM, or if the patient has had similar complaints in the past is significant in determining whether the patient has had DM for a while or if it is a new diagnosis. Past History Past medical history. Any previous relevant medical condition must be enquired by the paramedic. Paramedics need to obtain any past DM diagnosis, whether it is DM type I or II and any associated complications. Several previous DKA episodes are an indication of poorly controlled or suboptimal control of DM, or an unrecognized secondary pathology such as Addison's disease, thyroid dysfunction and coeliac disease. Any other conditions that the patient might have suffered from are also identified since some heart disease particularly myocardial infarction are common precipitating factors of DKA. Past gynaecological and obstetric history. DM can occur in pregnant patients as gestational DM putting such patients at risk of developing DKA. Paramedics should examine antenatal care records of such patients. Obstetrics’ complications such as puerperal sepsis and obstetrical hemorrhage can be a source of trauma leading to DKA (Molitch 1990, p. 643). Family History. Relevant family history should be documented. Patient or guardian should be questioned about any family history of DM. Since autosomal inheritance is common with type II DM, a positive family history of DM may increase the likelihood of a family member being diagnosed with DM too (Molitch 1990, p. 644). Medication and Allergies History Paramedics should enquire whether the patient has taken or is on any medication. This includes any over-the-counter or recreational medication. Some drugs such as thiazide diuretics, corticosteroids, pentamidine and sympathomimetics alter carbohydrate metabolism. These drugs can be the underlying precipitating agents in development of DKA (Umpierrez, Murphy & Kitabchi 2001, p. 29). If patient is on anti-diabetic medications, paramedics should investigate whether patient has been compliant and adheres to the prescribed dosages of the drugs. Patients who skipped taking their hypoglycemic agents are at risk of developing DM complications such as DKA. Musey et al. (1995) demonstrated that 55% of patients admitted with DKA had stopped their insulin therapy by themselves (p. 485). Type I DM patients who stopped taking insulin exhibit DKA symptoms as early as three days after their last insulin dose (Musey et al. 1995, p.485). Paramedics should also identify if the patient has any known allergies. This knowledge is important in making the right medication choices since hypersensitivity reactions may occur as a result of an allergenic active drug ingredient or excipient. Such reactions may result in anaphylactic shock that may aggravate the hypovolemic shock in DKA (Anand 2014). Social History Social history includes patient’s occupation, hobbies, living conditions, smoking status and history, drug dependence and alcohol use (CICS 2013, p. 7). Living condition and occupation may put a person at risk of certain infections that may precipitate DKA. Alcohol use especially binge drinking has also been associated with DKA, hence, the significance of alcohol history in patients with DKA (Pischke 2001, p. 44). Systems Review General questions. Paramedics should also enquire about changes in patient’s appetite, energy and weight. Weight loss is common in type I DM patients (Rhaghavan 2014). In DKA, weight loss is secondary to cellular starvation despite adequate food intake. Appetite increase is due to polyphagia associated with DM (Rhaghavan 2014). Patient may also feel weak due to impaired utilization of glucose in tissue as a result of insulin inadequacy. Cardiovascular system (CVS). A system review of the CVS may elicit signs and symptoms which are not identified in the above history. In DKA, blood supply may be reduced due to a decrease in blood volume after severe dehydration. Consequently, chest discomfort may be experienced due to decreased pulmonary circulation (CICS 2013, p. 8). Myocardial infarction is a common precipitating factor of DKA, therefore, patients may exhibit pain in their left chest exacerbating the above chest discomfort (Rhaghavan 2013). Respiratory system. Difficulties in breathing may arise from an underlying infection such as pneumonia (Kamangar 2013). Therefore, paramedics should enquire whether patient experiences difficulties in breathing, or dyspnea. If patient admits to coughing, paramedic should ask about the appearance of sputum, if any. If the cough is painful, it is important to obtain a description of the pain as the character of the pain may help diagnose an underlying infection. Intense, unrelenting chest pain lasting 30-60 min may be associated with myocardial infarction (MI) (Zakari 2014). Gastrointestinal system. Common gastrointestinal symptoms occurring in DKA patients include anorexia, vomiting and abdominal pain that may be non-specific (Colin 2014). Patient may inform paramedics of having experienced symptoms or paramedics themselves may obtain this information from the patient’s surrounding environment as patient’s vomitus may be visible in the environment. Renal system. Urinary tract infections may precipitate DKA (Rhaghavan 2014). In such cases, UTI symptoms should be elicited. A dull, constant pain in the lumbar regions may suggest renal infection such as pyelonephritis that is also characterized by dysuria (CICS 2013, p. 10). Neurological review. DKA patient may report lassitude (Umpierrez, Murphy & Kitabchi 2002, p. 29). Visual disturbance or poor vision may also be reported in chronic cases of poorly controlled DM (American Diabetic Association [ADA] 2014). Other neurological symptoms such as tingling and burning sensation and sensory loss can be present in DKA patient as a manifestation of diabetic neuropathy, a long term complication of DM (ADA 2014) Assessment of a DKA Patient: Clinical Examination Initial Impression. It is paramount that paramedics should provide a distance of about half to one meter from the patient and examine or assess factors such as discomfort or comfort levels, color, work of breathing, cognitive function and nutritional status (SCIS 2013, p. 14). This initial assessment will give paramedics an early impression of patient’s stability. Comfort/discomfort levels. Abdominal pain associated with DKA can be mild or severe depending on the extensity of acidosis (Umpierrez, Murphy & Kitabchi 2002, p. 29). Abdominal pain also occurs in severe dehydration and causes patient to be uncomfortable and distressed (Brenner 2006, p. 53). Color. DKA patient’s skin or mucous membranes may be pallor due to massive loss of fluids and electrolytes resulting in decreased blood flow to tissues and hypotension (Rhaghavan 2014) Work of breathing. Signs of respiratory distress, if any, are discussed in the physical examination of the respiratory system. The respiratory pattern in patients with DKA may be deep and rapid, defined as Kussmaul breathing as a result of respiratory compensation of metabolic acidosis (Umpierrez Murphy & Kitabchi 2002, p. 30). Nutritional status. DKA in new onset Type I DM patients may present with an acute decrease in body weight associated with tissue starvation due to impaired glucose utilization (Rhaghavan 2013; Musey et al. 1995, p. 485). Moreover, excessive fluid loss also contributes to weight loss. Cognitive status. AVPU score may be used to assess a DKA patient’s cognitive status. Patient may be (1) alert and conscious responding appropriately to the questions, (2) respond by grunts or groans, (3) respond to painful stimuli only, or (4) unresponsive (Blaber & Harris 2011, p. 3). DKA patients are occasionally indifferent or apathetic and irritable. Therefore, their attitude should not be misconstrued as a neurological symptom (Sellers & Ludwig 2013, p. 13). As DKA worsens, AVPU scores of less than A may be obtained. The deterioration in cognitive function is attributable to extreme acidosis and osmolarity in DKA patients (Edge 2013, p. 3). Clinical Examination of the Hands Due to severe dehydration associated with DKA, patients may experience hypovolemic shock which is characterized by cold, pale and sweaty hands (SCIS 2014, p. 15). Some diabetic patients have medic alert bracelets on their wrists that are useful especially for comatose patients with no significant history (Sellers & Ludwig 2012, p. 12). Pulse. In DKA, radial pulse may be irregular if the precipitating factor is MI (Zafari 2014). An elevated radial pulse is commonly a manifestation of tachycardia in response to the prevailing hypovolemia (Zafari 2014). However, tachycardia may be a result of other causes such as heart diseases, alcohol intoxication or an underlying infection or condition (Zafari 2014). Clinical Examination of Head and Neck. Dehydration is common in patients with DKA, and it is manifested by sunken eyes, dry mucous membrane and reduced skin turgor (Musey et al. 1995, p. 485). The latter is assessed by pinching the skin above the clavicle. Dry mucous membrane is observed from the lips and tongue and the mouth should also be checked for any ulcers. Mouth ulcers may be present in patients with DKA if their DM has been poorly controlled for a long time (ADA 2014). Clinical Examination of Systems in the Chest The chest encompasses the respiratory and cardiovascular system. Proper examination of the chest requires the patient to be sited at an angle of 45 degrees and may be required to lean forward when examining the back (SCIS 2013, p. 18). Respiratory System. Respiratory signs to examine in a patient with DKA include the work of breathing and breath odor. Airways and breathing may be impaired if there is an underlying respiratory tract infection such as pneumonia – a disease known to precipitate DKA (Kamangar 2013). Paramedics may smell a ‘fruity’ odor emanating from patient’s breath. The fruity odor in expired air is due to the presence of ketones that escape from blood through the lung’s alveoli as ketone levels in blood exceed their extraction and utilization (Rhaghavan 2014). Inspection. The chest is inspected for its symmetry, scars, rate and depth of breathing. Chest scars might suggest lung surgery for TB, trauma or recurrent pneumothoraces which may be precipitate DKA if they occurred in recent time (Rhaghavan 2013). Lung asymmetry may be due to pneumothorax or pleural effusion. The latter is a clinical characteristic of severe bacterial pneumonia which may precipitate DKA (Kamangar 2013). Palpation. It is important to elicit any other underlying disease or traumatic condition. A rare palpation finding may include “crackling” sensation on the chest wall referred to as subcutaneous emphysema (SE) (Bodenham 2008, p. 207). SE may herald an existing pneumothorax common in severe pulmonary TB and bacterial pneumonia which precipitate DKA (Bodenham 2008, p. 207). Percussion. It may aid in identifying any underlying condition that may precipitate DKA. Areas of dullness over the lung, identified through percussion, may be caused by fluid accumulation in pulmonary consolidation – a diagnostic symptom of pneumonia (SCIS 2013, p. 19). Auscultation. This technique, through a stethoscope, may be used to obtain symptoms related to an underlying disease such as pneumonia and MI that are known to precipitate DKA. Added sounds such as crackles and plural rub may be heard in pneumothorax and pneumonic consolidation (Kamangar 2013). Consolidation areas in the lungs may also produce bronchial breath sounds on auscultation. DKA patients with a concurrent MI may experience wheezing in addition to the DKA symptoms (Zafari 2014). Identifying a known DKA precipitating factor aids in planning for the step-wise management of a patient with DKA. Cardiovascular System (CVS). The thoracic cavity is assessed for signs of disease and cardiac symptoms related to DKA. A systolic blood pressure lower than 100mmHg indicates severe DKA that requires fluid resuscitation. Nevertheless, septic and cardiogenic shock should also be ruled out as they also cause such decrease in systolic blood pressure (Brenner 2006, p. 54). If, on palpation, the apical impulse is laterally displaced, MI may be implicated as a precipitating factor in DKA (Zafari 2013). Auscultation of the heart may reveal tachycardia that occurs as an autonomic counter response to hypovolemia in patients with DKA, and as a symptom of an underlying DKA precipitating condition such as MI (Zafari, 2013). Clinical Examination of the Abdomen. Inspection of the abdomen may reveal bruised insulin injection sites on the abdomen (Colin 2014). Such bruises should not be relied upon as a confirmatory symptom for DM since they might be caused by physical trauma. Nevertheless, it aids in narrowing down on differential diagnosis to DM and, consequently, DKA. Clinical Examination of the Neurological System. This involves assessing the level of consciousness in patients with DKA. Pupil reaction and size are checked to assess decrease of consciousness that may be associated with drug ingestion such as alcohol that may also precipitate DKA (Rhaghavan 2014). AVPU scores of less than A may necessitate a further thorough neurological assessment using GCS. GCS scores of less than eight may be obtained in an extreme acidosis and high osmolarity levels that further deteriorate mental function in patients with DKA (Colin 2014) Other Investigations Glucometers should be used as an initial blood glucose assessment and during treatment monitoring. Keto-strips or urine dipstick should be used to obtain serum and urine ketone levels. Glucose reading of above 250mg/dl, arterial blood pH less than 7.3, and positive urine ketone level more than 3mmol/l will confirm the diagnosis of DKA (Umpierrez, Murphy & Kitabchi 2002, p. 30). In addition to positive ketonuria and glycosuria, urinalysis can also show elevated squamous epithelial cells and white blood cells in the presence of underlying urinary tract infection(s) that can precipitate DKA (Lerma 2013). Complete blood count (CBC) picture showing elevated white blood cells may indicate and underlying bacterial infection that precipitates DKA. However, an elevated CBC without a left shift is a common finding in DKA not precipitated by any bacterial infection (Pischke 2001, p. 43). Electrolyte abnormalities found in DKA patients can include elevated serum potassium more than 5.0 mmol/L, serum bicarbonate of less 15 mmol/L and serum sodium of lower than 135mmol/L (Pischke 2001, p. 45). These electrolyte abnormalities result in increased anion gap more than 10 mmol/L (Umpierrez, Murphy & Kitabchi 2002, p. 30). In patient’s whose diabetes has been poorly controlled, glycated hemoglobin A1c is usually elevated more than 6% (Akbay et al. 2013, p. 134). Cardiac enzymes such as troponin, a protein released in myocardial necrosis, is present in serum of patients whose DKA is precipitate by MI in addition to elevated serum lactate dehydrogenase (Zafari 2014). Chest radiography showing areas of consolidation and opacity will be useful in supporting the diagnosis of pneumonia as a precipitating factor in DKA (Kamangar 2013). Conclusion Assessment and diagnosis of DKA not only requires identification of DKA symptoms, but also the examination of physical symptoms and other related conditions known to precipitate DKA. Paramedics rely upon their assessment and diagnostic skills to diagnose DKA. Therefore, they should be well trained to understand and diagnose DKA by identifying its precipitating factors and implement emergency management measures. Reference List Agabegi, SS & Agabegi, ED 2008, Step-up to medicine, 2nd edn, Lippincott Williams & Wilkins, Baltimore. Akbay, S, Yel A, Yildirimer, U, Can, S & Dundar, B 2013, Diabetic Ketoacidosis presenting with pseudonormoglycemia in a 15-year old girl with type 1 diabetes mellitus. J Clin Res Pediatr Endocrinol, vol. 5, no. 2, pp. 133-135. 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