Episode 894: DKA and HHS

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

What are DKA and HHS?

• DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states.

DKA

• More common in type 1 diabetes.

• Triggered by decreased circulating insulin.

• The body needs energy but cannot use glucose because it can’t get it into the cells.

• This leads to increased metabolism of free fatty acids and the increased production of ketones.

• The buildup of ketones causes acidosis.

• The kidneys attempt to compensate for the acidosis by increasing diuresis.

• These patients present as dry and altered, with sweet-smelling breath and Kussmaul (fast and deep) respirations.

HSS

• More common in type 2 diabetes.

• In this condition there is still enough circulating insulin to avoid the breakdown of fats for energy but not enough insulin to prevent hyperglycemia.

• Serum glucose levels are very high – around 600 to 1200 mg/dl.

• Also presents similarly to DKA with the patient being dry and altered.

Important labs to monitor

• Serum glucose

• Potassium

• Phosphorus

• Magnesium

• Anion gap (Na - Cl - HCO3)

• Renal function (Creatinine and BUN)

• ABG/VBG for pH

• Urinalysis and urine ketones by dipstick

Treatment

• Identify the cause, i.e. Has the patient stopped taking their insulin?

• Aggressive hydration with isotonic fluids.

• Normal Saline (NS) vs Lactated Ringers (LR)?

• LR might resolve the DKA/HHS faster with less risk of hypernatremia.

• Should you bolus with insulin?

• No, just start a drip.

• 0.1-0.14 units per kg of insulin.

• Make sure you have your potassium back before starting insulin as the insulin can shift the potassium into the cells and lead to dangerous hypokalemia.

• Should you treat hyponatremia?

• Make sure to correct for hyperglycemia before treating. This artificially depresses the sodium.

• Should you give bicarb?

• Replace if the pH < 6.9. Otherwise, it won’t do anything to help.

• Don’t intubate, if the patient is breathing fast it is because they are compensating for their acidosis.

References

1. Andrade-Castellanos, C. A., Colunga-Lozano, L. E., Delgado-Figueroa, N., & Gonzalez-Padilla, D. A. (2016). Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. The Cochrane database of systematic reviews, 2016(1), CD011281. https://doi.org/10.1002/14651858.CD011281.pub2

2. Chaithongdi, N., Subauste, J. S., Koch, C. A., & Geraci, S. A. (2011). Diagnosis and management of hyperglycemic emergencies. Hormones (Athens, Greece), 10(4), 250–260. https://doi.org/10.14310/horm.2002.1316

3. Dhatariya, K. K., Glaser, N. S., Codner, E., & Umpierrez, G. E. (2020). Diabetic ketoacidosis. Nature reviews. Disease primers, 6(1), 40. https://doi.org/10.1038/s41572-020-0165-1

4. Duhon, B., Attridge, R. L., Franco-Martinez, A. C., Maxwell, P. R., & Hughes, D. W. (2013). Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. The Annals of pharmacotherapy, 47(7-8), 970–975. https://doi.org/10.1345/aph.1S014

5. Modi, A., Agrawal, A., & Morgan, F. (2017). Euglycemic Diabetic Ketoacidosis: A Review. Current diabetes reviews, 13(3), 315–321. https://doi.org/10.2174/1573399812666160421121307

6. Self, W. H., Evans, C. S., Jenkins, C. A., Brown, R. M., Casey, J. D., Collins, S. P., Coston, T. D., Felbinger, M., Flemmons, L. N., Hellervik, S. M., Lindsell, C. J., Liu, D., McCoin, N. S., Niswender, K. D., Slovis, C. M., Stollings, J. L., Wang, L., Rice, T. W., Semler, M. W., & Pragmatic Critical Care Research Group (2020). Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA network open, 3(11), e2024596. https://doi.org/10.1001/jamanetworkopen.2020.24596

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

Contributor: Aaron Lessen MD

Educational Pearls:

• Button batteries cause alkaline corrosion and erosion of the esophagus when swallowed

• Children swallow button batteries, which create a medical emergency as they can perforate the esophagus

• A recent study compared various home remedies as first-aid therapy for button battery ingestion

• Honey, jam, normal saline, Coca-Cola, orange juice, milk, and yogurt

• The study used a porcine esophageal model to assess resistance to alkalinization with the different home remedies

• Honey and jam demonstrated a significantly lower esophageal tissue pH compared with normal saline

• Histologic changes in the tissue samples appeared 60 minutes later with honey and jam compared with normal saline

• These treatments do not preclude medical intervention and battery removal

References

1. Chiew AL, Lin CS, Nguyen DT, Sinclair FAW, Chan BS, Solinas A. Home Therapies to Neutralize Button Battery Injury in a Porcine Esophageal Model. Ann Emerg Med. 2023:1-9. doi:10.1016/j.annemergmed.2023.08.018

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

What can you do to control bleeding in a penetrating wound?

• Apply direct pinpoint pressure on the wound as well as proximal to the wound.

• Build a compression dressing.

How do you build a compression dressing?

• Think about building an upside-down pyramid with the gauze.

• Consider coagulation agents such as an absorbent gelatin sponge material, microporous polysaccharide hemispheres, oxidized cellulose, fibrin sealants, topical thrombin, or tranexamic acid.

What are the indications to use a tourniquet?

• The Stop The Bleed campaign recommends looking for the following features of “life-threatening” bleeding.

• Pulsatile bleeding.

• Blood is pooling on the ground.

• The overlying clothes are soaked.

• Bandages are ineffective.

• Partial or full amputation.

• And if the patient is in shock.

How do you put on a tourniquet?

• If using a Combat Application Tourniquet (C-A-T) tourniquet, apply it proximal to the wound, then rotate the plastic rod until the bleeding stops. Then secure the plastic rod with a clip and make sure the Velcro is in place.

• Mark the time - generally, there is a spot on the tourniquet to write.

• Have a plan for the next steps. Does the patient need emergent surgery? Do they need to be transfered?

How long can you leave a tourniquet on?

• Less than 90 minutes.

What are the risks?

• Nerve injury.

• Ischemia.

References

1. Latina R, Iacorossi L, Fauci AJ, Biffi A, Castellini G, Coclite D, D'Angelo D, Gianola S, Mari V, Napoletano A, Porcu G, Ruggeri M, Iannone P, Chiara O, On Behalf Of Inih-Major Trauma. Effectiveness of Pre-Hospital Tourniquet in Emergency Patients with Major Trauma and Uncontrolled Haemorrhage: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2021 Dec 6;18(23):12861. doi: 10.3390/ijerph182312861. PMID: 34886586; PMCID: PMC8657739.

2. Martinson J, Park H, Butler FK Jr, Hammesfahr R, DuBose JJ, Scalea TM. Tourniquets USA: A Review of the Current Literature for Commercially Available Alternative Tourniquets for Use in the Prehospital Civilian Environment. J Spec Oper Med. 2020 Summer;20(2):116-122. doi: 10.55460/CT9D-TMZE. PMID: 32573747.

3. Resources poster booklet. (n.d.). Stop the Bleed. https://www.stopthebleed.org/resources-poster-booklet/

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

Contributors: Kali Olson PharmD, Travis Barlock MD, Jeffrey Olson MS2

Summary:

In this episode of Pharmacy Phriday, Dr. Kali Olson joins Dr. Travis Barlock and Jeffrey Olson in studio to discuss a variety of interesting topics in the form of a segment show. Dr. Kali Olson earned her Doctorate of Pharmacy from the University of Colorado, Skaggs School of Pharmacy and completed a PGY1 residency at Detroit Receiving Hospital and a PGY2 residency in Emergency Medicine at Denver Health. She now works as an Emergency Medicine Pharmacist at Denver Health. 

In segment one of the show, Kali and Travis answer the Get-To-Know-You questionnaire. In segment two, they work together to answer a series of pharmacy-based riddles. In segment three they play a “Balderdash” like game in which they guess the definitions of medical jargon. In segment four they play the Number Needed to Treat game, invented by the AFP podcast. And in segment five they work together to answer a question about a far-out scenario involving medications and time travel!

References

·       American Family Physician Podcast, https://www.aafp.org/pubs/afp/multimedia/podcast.html

·       Gragnolati, A. (2022, May 5). The Yuzpe method of emergency contraception. GoodRx. https://www.goodrx.com/conditions/emergency-contraceptive/yuzpe-method

·       Manikandan S, Vani NI. Holiday reading: Learning medicine through riddles. CMAJ. 2010 Dec 14;182(18):E863-4. doi: 10.1503/cmaj.100466. PMID: 21149530; PMCID: PMC3001539.

·       Riddle Me This: Mixing Medicine, https://peimpact.com/riddle-me-this-mixing-medicine/

·       https://thennt.com/nnt/corticosteroids-treatment-kawasaki-disease-children/

·       https://thennt.com/nnt/aspirin-acute-ischemic-stroke/

·       https://thennt.com/nnt/tranexamic-acid-treatment-epistaxis/

·       https://thennt.com/nnt/antibiotics-culture%e2%80%90positive-asymptomatic-bacteriuria-pregnant-women/

Produced, Hosted, Edited, and Summarized by Jeffrey Olson MS2 | Additional editing by Jorge Chalit, OMSII

Contributor: Taylor Lynch MD

Educational Pearls

• Hypothermia is defined as a core body temperature less than 35 degrees Celsius or less than 95 degrees Fahrenheit 

• Mild Hypothermia: 32-35 degrees Celsius

• Presentation: alert, shivering, tachycardic, and cold diuresis

• Management: Passive rewarming i.e. remove wet clothing and cover the patient with blankets or other insulation

• Moderate Hypothermia: 28-32 degrees Celsius

• Presentation: Drowsiness, lack of shivering, bradycardia, hypotension

• Management: Active external rewarming

• Severe Hypothermia: 24-28 degrees Celsius

• Presentation: Heart block, cardiogenic shock, no shivering

• Management: Active external and internal rewarming

• Less than 24 degrees Celsius

• Presentation: Pulseless, ventricular arrhythmia

• Active External Rewarming

• Warm fluids are insufficient for warming due to a minimal temperature difference (warmed fluids are maintained at 40 degrees vs. a patient at 30 degrees is not a large enough thermodynamic difference)

• External: Bear hugger, warm blankets

• Active Internal Rewarming

• Thoracic lavage (preferably on the patient’s right side)

• Place 2 chest tubes (anteriorly and posteriorly); infuse warm IVF anteriorly and hook up the posterior tube to a Pleur-evac

• Warms the patient 3-6 Celsius per hour

• Bladder lavage

• Continuous bladder irrigation with 3-way foley or 300 cc warm fluid

• Less effective than thoracic lavage due to less surface area

• Pulseless patients

• ACLS does not work until patients are rewarmed to 30 degrees

• High-quality CPR until 30 degrees (longest CPR in a hypothermic patient was 6 hours and 30 minutes)

• Give epinephrine once you reach 35 degrees, spaced out every 6 minutes

• ECMO is the best way to warm these patients up (10 degrees per hour)

• Pronouncing death must occur at 32 degrees or must have potassium > 12

References

1. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 1: Introduction. Circulation. 2005;112(24 SUPPL.). doi:10.1161/CIRCULATIONAHA.105.166550

2. Brown DJA, Burgger H, Boyd J, Paal P. Accidental Hypothermia. N Engl J Med. 2012;367:1930-1938. doi:10.1136/bmj.2.5543.51-c

3. Dow J, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med. 2019;30(4S):S47-S69. doi:10.1016/j.wem.2019.10.002

4. Kjærgaard B, Bach P. Warming of patients with accidental hypothermia using warm water pleural lavage. Resuscitation. 2006;68(2):203-207. doi:10.1016/j.resuscitation.2005.06.019

5. Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219. doi:10.1016/j.resuscitation.2021.02.011

6. Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest - Report of a case and review of the literature. Resuscitation. 2005;66(1):99-104. doi:10.1016/j.resuscitation.2004.12.024

Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

Contributor: Jared Scott MD

Educational Pearls:

• Croup is a respiratory condition typically caused by a viral infection (e.g., parainfluenza). The disease is characterized by inflammation of the larynx and trachea, which often leads to a distinctive barking cough.

• A common treatment for croup is the powerful steroid dexamethasone, but it can take up to 30 minutes to start working.

• A folk remedy for croup is to take the afflicted child outside in the cold to help them breathe better, but does it really work?

• A 2023 study in Switzerland, published in the Journal of Pediatrics, investigated whether a 30-minute exposure to outdoor cold air could improve mild to moderate croup symptoms before the onset of steroid effects.

• The randomized controlled trial included children aged 3 months to 10 years with croup.

• After receiving a single-dose oral dexamethasone, participants were exposed to either outdoor cold air or indoor room air. The primary outcome was a decrease in the Westley Croup Score (WCS) by at least 2 points at 30 minutes.

• The results indicated that exposure to outdoor cold air, in addition to dexamethasone, significantly reduced symptoms in children with croup, especially in those with moderate cases.

References

1. Siebert JN, Salomon C, Taddeo I, Gervaix A, Combescure C, Lacroix L. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Sep 1;152(3):e2023061365. doi: 10.1542/peds.2023-061365. PMID: 37525974.

Summarized by Jeffrey Olson, MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

Contributor: Aaron Lessen MD

Educational Pearls:

Does the size of a blood pressure (BP) cuff matter?

A recent randomized crossover trial revealed that, indeed, cuff size can affect blood pressure readings

Design

• 195 adults with varying mid-upper arm circumferences were randomized to the order of BP cuff application:

• Appropriate

• Too small

• Too large

• Individuals had their mid-upper arm circumference measured to determine the appropriate cuff size

• Participants underwent 4 sets of triplicate blood pressure measurements, the last of which was always with the appropriately sized cuff

Results

• In individuals requiring a small cuff, the use of a regular cuff resulted in blood pressure readings 3.6 mm Hg lower than with the small cuff

• In individuals requiring large cuffs, the use of a regular cuff resulted in pressures 4.8 mm Hg higher than with the large cuffs

• In individuals requiring extra-large cuffs, the use of a regular cuff resulted in pressures 19.5 mm Hg higher than with extra-large cuffs

Conclusion

• Miscuffing results in significantly inaccurate blood pressure measurements

• It is important to emphasize individualized BP cuff selection

References

1. Ishigami J, Charleston J, Miller ER, Matsushita K, Appel LJ, Brady TM. Effects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial. JAMA Intern Med. 2023;183(10):1061-1068. doi:10.1001/jamainternmed.2023.3264

Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit

Contributor: Aaron Lessen MD

Educational Pearls:

Is the adage, “GCS of 8, you’ve got to intubate” accurate? A recent study published in the November 2023 issue of JAMA attempted to answer this question.

Design

• Multicenter, randomized trial, in France from 2021 to 2023.

• 225 patients experiencing comatose in the setting of acute poisoning were randomly assigned to either a conservative airway strategy of withholding intubation or “routine practice” of much more frequent intubation.

• The primary outcome was a composite endpoint including in-hospital death, length of intensive care unit stay, and length of hospital stay.

• Secondary outcomes included adverse events from intubation and pneumonia within 48 hours.

Results

• Results showed that in the intervention group (with intubation withholding), only 16% of patients were intubated, compared to 58% in the control group.

• No in-hospital deaths occurred in either group.

• The intervention group demonstrated a significant clinical benefit for the primary endpoint, with a win ratio of 1.85 (95% CI, 1.33 to 2.58).

• The conservative airway management strategy also saw a statistically significant decrease in adverse events from intubation and pneumonia.

Conclusion

• Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit.

• This suggests that a judicious approach to intubation is appropriate in many other settings and clinicians should rely on more than the GCS to make this decision.

References

1. Freund Y, Viglino D, Cachanado M, Cassard C, Montassier E, Douay B, Guenezan J, Le Borgne P, Yordanov Y, Severin A, Roussel M, Daniel M, Marteau A, Peschanski N, Teissandier D, Macrez R, Morere J, Chouihed T, Roux D, Adnet F, Bloom B, Chauvin A, Simon T. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968; PMCID: PMC10687712.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII

Contributor: Aaron Lessen MD

Educational Pearls:

• A 2013 study randomized families of those in cardiac arrest into two groups:

• Actively offered patients’ families the opportunity to observe CPR

• Follow standard practice regarding family presence (control group)

• Of the 266 relatives that received offers to observe CPR, 211 (79%) accepted vs. 43% in the control group observed CPR

• The study assessed a primary end-point of PTSD-related symptoms 90 days after the event

• Secondary end-points included depression, anxiety, medicolegal claims, medical efforts at resuscitation, and the well-being of the healthcare team

• The frequency of PTSD-related symptoms was significantly higher in the control group

• Lower rates of anxiety and depression for the families who witnessed CPR

• There were no effects on resuscitation efforts, patient survival, medicolegal claims, or stress on the healthcare team

• If families choose to witness CPR, it’s beneficial to have someone with the family to explain the process

References

1. Jabre P, Belpomme V, Azoulay E, et al. Family Presence during Cardiopulmonary Resuscitation. N Engl J Med. 2013;368(11):1008-1018. doi:10.1056/NEJMoa1203366

Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit

Contributor: Ricky Dhaliwal, MD

Educational Pearls:

Croup

• Caused by:

• Parainfluenza, Adenovirus, RSV, Enterovirus (big right now)

• Age range:

• 6 months to 3 years

• Symptoms:

• Barky cough

• Inspiratory stridor (Severe = stidor at rest)

• Use the Westley Croup Score to gauge the severity

• Treatment:

• High flow, humidified, cool oxygen

• Dexamethasone 0.6 mg/kg oral, max 16mg

• Severe: Racemic Epinephrine 0.5 mL/kg

• Consider heliox, a mixture of helium and oxygen

• Very severe: be ready to intubate

Bronchiolitis

• Caused by:

• RSV, Rhinovirus

• Symptoms are driven by secretions

• Symptoms:

• Cough

• Wheezing

• Dehydration (often the symptom that makes them look the worst)

• Age range:

• 2 to 6 months

• Treatment:

• Suctioning

• Oxygen

• IV fluids

• Nebulized hypertonic saline

• DuoNebs? No.

Asthma

• Caused by:

• Environmental factors

• Viral illness with a predisposition

• Treatment:

• Beta agonists

• Steroids

• Ipratropium

• Magnesium (relaxes smooth muscle)

References

• Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet. 2022 Jul 30;400(10349):392-406. doi: 10.1016/S0140-6736(22)01016-9. Epub 2022 Jul 1. PMID: 35785792.

• Hoch HE, Houin PR, Stillwell PC. Asthma in Children: A Brief Review for Primary Care Providers. Pediatr Ann. 2019 Mar 1;48(3):e103-e109. doi: 10.3928/19382359-20190219-01. PMID: 30874817.

• Midulla F, Petrarca L, Frassanito A, Di Mattia G, Zicari AM, Nenna R. Bronchiolitis clinics and medical treatment. Minerva Pediatr. 2018 Dec;70(6):600-611. doi: 10.23736/S0026-4946.18.05334-3. Epub 2018 Oct 18. PMID: 30334624.

• Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253.

• Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978 May;132(5):484-7. doi: 10.1001/archpedi.1978.02120300044008. PMID: 347921.

• https://www.mdcalc.com/calc/677/westley-croup-score

Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMSII