Intern Report 7.14

Case Presentation by Luda Khait, MD

CC: “My chest hurts”

HPI: The patient is a 56yo female who presents to the emergency department as a medical code for tachycardia. She is well known to the emergency department for multiple admissions for DKA. The patient is complaining of chest pain that started earlier today, however, is unable to provide us with any more history due to confusion. She is thrashing on the stretcher, moaning, and not fully responding to questions.

ROS: Unable to obtain secondary to medical condition

Past medical history: Diabetes mellitus with multiple admissions for DKA, glaucoma, hypertension, renal insufficiency, chronic anemia
Past surgical history: Unknown
Social history: Per EMR positive history of remote drug abuse.
Family history: Diabetes
Medications: Reports she is compliant with her Insulin 70/30 10U BID, other medications unknown
Allergies: NKDA
PMD: She states she has no regular doctor

Physical Exam:
- T: 36.0 – orally
- P: 119
- BP 124/70
- R 20
- O2 sat 98% RA

GENERAL: The patient appears agitated and is hyperpnic. She is wearing clothes that appear dirty and have holes in them. She does open her eyes spontaneously, she is unable to coherently answer questions, however, is moaning in response to questions and pain.

HEENT: Head normocephalic, atraumatic Conjunctivae are pink without pallor. Pupils are 3mm bilaterally, equal, round and reactive to light.

NECK: Supple. Trachea midline.

HEART: Tachycardic rate, regular rhythm, no murmurs, rubs or gallops

LUNGS: Lungs are clear to auscultation bilaterally, no wheezes, rales, or ronchi, increased ventilation, no retractions or use of accessory muscles.

ABDOMEN: The abdomen is soft, nondistended. It is diffusely tender to palpation no rebound or peritoneal signs, no increased tenderness at McBurney’s point, negative Murphy’s sign.

EXTREMITIES: Dorsalis pedis and radial pulses are 2+ bilaterally. No pedal edema.

NEUROLOGIC: The patient is alert. Her face appears symmetric. She smiles and closes her eyes symmetrically. She responds to some commands and moving all 4 extremities with good strength and purpose. We are unable to evaluate her speech at this time, since she is moaning in response to questions.

ED Course: 
In the resuscitation bay, the patient was immediately placed on an O2/cardiac monitor, which revealed an O2 sat of 98% on room air and sinus tachycardia. Nursing staff placed two large bore peripheral IV lines and basic labs were drawn. Two boluses of NS were started wide open. Accucheck revealed a CBG >600.

A 12-lead ECG was obtained:









Chest XR revealed no pneumothorax or pulmonary infiltrates.

BMP: Na 142, K 4.7, Cl 91, HCO3 5, BUN 42, Cr 2.25 BG 1,037
AG: 46
CBC: WBC 11.4, Hgb 9.6, Hct 31.5, Pl 438
ABG: 7.15/15/126/8.1
Beta Hydroxybuterate: >100


Question 1: What is the most likely cause of this patient’s change in mental status?
A)   Hyperglycemia
B)   Dehydration
C)   Hyperosmolarity
D)   Acidosis
E)   Hyponatremia

Question 2: In the treatment of DKA, what is the ABG pH for which bicarbonate therapy is recommended?
A) pH < 6.8
B) pH < 7.0
C) pH < 7.1
D) pH < 7.3

Question 3: In a diabetic patient with refractory hypoglycemia, what medication are you most suspecting responsible for this finding?
A)   Pioglitazone
B)   Glyburide
C)   Metformin
D)   Rosiglitazone

Part B: Name a treatment for hypoglycemia associated with Type II DM (not glucose in any form).


Answers & Discussion
1) C
3) B
Bonus) Octreotide

Question 1: C. The pathophysiology of DKA involves concurrent insulin deficiency and glucagon excess that combine to produce a hyperglycemic, dehydrated, acidotic patient that has profound electrolyte abnormalities. Although all of the above can contribute to altered mental status, the most important factor is hyperosmolarity, a result of hyperglycemia and dehydration. The renal tubules begins to excrete glucose in the urine (glycosuria) when the blood glucose reaches a level above 160-180 mg/dl; the proximal renal tubules become overwhelmed at that level and are unable to resorb the excess glucose. The excess glucose in the renal tubules draws water and other electrolytes, via an osmotic effect, into the urine. This osmotic diuresis along with dehydration from poor oral intake and vomiting promotes hyperosmolarity and altered mentation. Ketoacidosis is also an important factor that can determine mentation, however, it has a contributory effect with hyperosmolarity, rather than absolute effect on its own in DKA.

The formula for serum osmolality is = 2(Na+) + Glucose/18

One must be very careful when interpreting the laboratory values in a patient with suspected DKA. The serum sodium levels are often misleadingly low in hyperglycemic states. In profound dehydration, sodium levels are usually on the lower end secondary to hyperglycemia, hypertriglyceridemia, low salt intake, increased GI/renal losses, along with perspiration/insensible losses. The pathophysiology of falsely low sodium is due to water flowing from cells into the intracellular space due to the marked hyperosmolarity, creating a dilutional hyponatremia. The true value of sodium can be calculated by adding 1.3-1.6 to the sodium lab value for every 100mg/dL of glucose above the normal value. This calculation cannot be accurately used, however, if profound hyperlipidemia is noted. Hypertriglyceridemia is a common finding in DKA, owing to the fact of impaired lipoprotein lipase activity and overproduction of hepatic VLDLs. These lipids further promote dilution of the blood and falsely decrease sodium concentrations.












Question 2: B. The use of bicarbonate therapy in treating DKA is controversial. Successful treatment of DKA involves correction of dehydration, hyperglycemia, and electrolyte imbalances. Initially, ABCs should be established. The initial fluid therapy is directed toward total intravascular volume expansion as well as restoration of renal perfusion. Typically, normal saline is used at a rate of 15-20ml/kg /hr. If the patient is in hypovolemic shock, more fluids may be necessary. If the patient has other co-morbidities, such as heart failure or CKD, it is important to monitor the patient hemodynamically so to not fluid overload the patient.

In general, insulin administration shuts of ketogenesis and in turn will correct the acidosis. Bicarbonate therapy is generally not recommended by the ADA, unless the pH is below 7. Bicarbonate therapy has not been shown to improve outcomes and has actually been shown to worsen prognosis in patients with pH ranges of 6.9-7.1, and in fact, lower pH has been shown to directly inhibit further ketogenesis via a feedback mechanism. Bicarbonate shifts the oxygen-hemoglobin dissociation curve to the right via 2,3-DPG deficiency, worsening oxygen release in tissues. Also, quickly correcting the intravascular acidosis will terminate Kussmaul respirations, allowing the CO2 to cross readily into the brain circulation across the blood-brain barrier, making CSF acidic. In addition, administration of bicarbonate will drive potassium further into the cells, making hypokalemia even more pronounced. Finally, overaggressive use of bicarbonate administration may produce alkelemia later on in the treatment course, secondary to ketones being metabolized into CO2, water, and bicarbonate.

This is a guideline and the complete clinical picture should be considered, not just a number.











Question 3: B. Hypoglycemia is a major and most dangerous complication associated with both type 1 and type 2 diabetes. Severe hypoglycemia is typically defined as blood glucose levels below 40-50mg/dL associated with altered mentation. It occurs when patients use too much insulin/oral hypoglycemic medication and either have decreased oral intake, increased energy expenditure, or increase their insulin dosage. Patients that have had multiple bouts of hypoglycemia may become immune to the warning symptoms, causing what is known as hypoglycemia unawareness. This in turn can result in significant morbidity and mortality. Since their blood sugar can plummet without their awareness, these patients may become unresponsive and unarousable very quickly and without warning. Signs and symptoms of hypoglycemia are a result of adrenergic drive of epinephrine. These signs and symptoms include sweating, nervousness, tremor, tachycardia, and altered mentation.

Pioglitazone and Rosiglitazone are within the thiazolidinedione class of oral hypoglycemics. This class of medications reverses insulin resistance of the muscle and fat cells, and also acts on hepatocytes to a lesser degree decreasing gluconeogenesis. Hypoglycemia is not a known side effect of thiazolidinediones. Glyburide, on the other hand, is a longer acting oral hypoglycemic belonging to the sulfonylurea class. This class of hypoglycemics is known to cause hypoglycemia, especially after exercise or missed meal, after being discharged from the hospital, with use of longer acting medications, and malnourished patients, amongst others. This class of medications increases insulin release from the beta cells of the pancreas at any blood glucose concentration. Metformin does not typically cause hypoglycemia because it only works when there is a baseline insulin level within the body. It acts to increase insulin’s action rather than to stimulate its release.

Patients with suspected overdose on oral hypoglycemic agents should be observed for 24 hours if hypoglycemia recurs after initial treatment in the ED. Patients that are most at risk for refractory hypoglycemia are those with impaired renal function, pediatric patients, and those patients who have just been started on an oral hypoglycemic.

In addition to frequent glucose monitoring and replacement, treatment with an agent to inhibit insulin release, like octreotide (a somatostatin analogue) canbe used. The recommended dose for adults ranges from 50-100 mcg IV or SC every 12 hours. In fact, giving patients multiple doses of D50 to raise their blood sugar in turn will stimulate more insulin to be produced, given the sulfonylureas still in the system. Although the exact mechanism of action is not known, Octreotide will block the insulin release that is caused both by the sulfonylureas and dextrose.

Prior to discharge, a meal should be given to the patient to make sure that the patient can tolerate oral feedings and this meal can begin to replenish the glycogen stores. Close outpatient follow-up is necessary to re-evaluate the oral hypoglycemic agent dose.


Conn’s Current Therapy 2014 Edward T. Bope, Rick D. Kellerman; Elsevier Inc, 2014

Rosen’s Emergency Medicine

Kitabchi A, et al. Hyperglycemia Crisis in Adult Patients with Diabetes. Diabetes Care, Volume 29, #12. December 2006.











Filed under: Intern Report

A “bread and butter” case with some “toast…

A “bread and butter” case with some “toast and jam” for pearls
Episode 144

June 2, 2014

Upcoming Conference & Workshop:
International Conference on Emergency Medicine 
June 10, 2014 in Hong Kong
Differential for Narrow & Irregular Tachycardias
1. Atrial Fibrillation
  • No distinct regular atrial activity
  • Causes an irregularly irregular rhythm
  • "Lumpy bumby" with no clear P waves that map out
  • Treatment is cardioversion in unstable patients

​2. Atrial flutter with variable conduction

  • Regular atrial activity (flutter waves) at ~ 300 bpm
  • Variable ventricular conduction causes an irregular rhythm
  • P waves may be subtle and easy to miss (look closely at V1)
  • Treatment is cardioversion in unstable patients

3. Multifocal atrial tachycardia (MAT)

  • Clear atrial activity that is irregular (no dominant atrial focus)
  • Causes an irregularly irregular rhythm (some P waves may not be conducted)
  • At least 3 morphologically distinct P waves
  • Variable intervals (P-P, P-R, R-R)
  • Aberrant conduction may be present
  • Ventricular rate usually 100-150
  • ​When rate < 100, called “wandering atrial pacemaker”
  • Most often associated with pulmonary disease (acute or chronic)
  • Beta blockers, Theophylline, HypoMg2+ and HypoK+ may be contributing factors
  • Not a destabilizing rhythm, treat the underlying cause

Never shock sinus tachycardia or MAT!

Still hungry? How about some more narrow complex tachycardia ?
Posted in Uncategorized |


The British ATACC concept – Anaesthesia Trauma And Critical Care – is as the name implies a course focusing on the anaesthestic (non-surgical) part of trauma and critical care treatment. The course was developed as a more advanced and up-to-date … Continue reading

Hennepin County EM Residents at SAEM


The Hennepin County Emergency Medicine crew made it back home after an exciting and productive week in Dallas, Texas for SAEM’s annual conference.  This year’s conference boasted an impressive 102 didactic sessions, 794 abstract presentations, competitions including SimWars and SonoGames, as well as a variety of different workshops and leadership forums. Here are a few of the highlights…

Hennepin Presentations

We had a very active year in research and were proud to have many of our residents and faculty present abstracts through oral and poster presentations.  Below are all of the Hennepin abstracts presented at SAEM…

Brian Driver presenting at SAEM 2014

Brian Driver presenting at SAEM 2014

  • Jim Miner, MD- Use of MigraineBox™ Head and Neck Cooling Bath for Treatment of Primary Headaches in the Emergency Department
  • Johanna Bischoff, Steve Smith, et al- ST Depression In Lead I Is Not A Reliable Predictor Of Right Ventricular Infarction In Inferior STEMI
  • Brian Driver, John McGill, and Rob Reardon- ED Airway Management of Severe Angioedema: A Single Center’s Experience
  • Jeff Ho, Jim Miner, Johanna Moore- Stress Biomarkers in Patients Undergoing Treatment for Severe Pain from Extremity Fractures
  • Jeff Ho, Jim Miner, Johanna Moore- Stress Biomarkers in Patients Undergoing Treatment for Severe Agitation and Confusion in the Emergency Department
  • Jim Miner, Roma Patel MPH- The Association of Gender with Pain Measurements
  • Brian Driver, Jim Miner, Johanna Moore, Rob Reardon, et al.- Ketamine Versus Etomidate for ED Rapid Sequence Intubation
  • Johanna Bischoff, Brian Driver, Jim Miner, Travis Olives- Administration of IV Fluids and Subcutaneous Insulin is Not Associated with Significant Glucose Reduction in ED Patients with Severe Hyperglycemia
  • Jeff Ho, Jim Miner, Johanna Moore, et al.- An Evaluation Of Two Conducted Electrical Weapons Using A Swine Comparative Cardiac Safety Model

In addition to oral and poster presentations, two of our faculty members presented in didactic panel sessions.  Excellent work by Dr. Dunlop (@dunlop0059) and Dr. Hart (@hartd00)!

Dr. Dunlop- Ultrasound in Resource-limited Settings: Discussion of Use, Benefits, Research and Sustainable Program Design

Dr. Hart- Achieving your Milestones Through Simulation

SIM Wars

Johanna Bischoff, Brian Driver (@brian_driver), Jackie Gadbois, and Travis Olives were the Hennepin representatives competing in the annual SimWars competition, where EM resident teams from across the country compete in a simulated patient encounter to show off their skills in communication, teamwork, and patient-centered care.  We were narrowly beat out by the University of Kentucky team, who went on to win the entire competition.  Congratulations to everyone!


SAEM 14 SimWars Team: Travis, Brian, Johanna, and Jackie from left to right

SAEM 14 SimWars Team: Travis, Brian, Johanna, and Jackie from left to right

Clinical Pearls

After attending all the abstract and didactic presentations each day, the residents got together to share their what they had learned.  Here are some of the more salient pearls from these discussions…

  • There was a lot of ketamine love at SAEM, with more and more widespread use for pain and sedation
  • There was a big push for cost effective medicine, encouraging physicians to Choose Wisely.  Some hospitals are now even showing the cost of labs/tests/drugs in the order.  There was a lot of discussion about cost vs charges, as well.
  • Drs. Jeff Klein and Pawan Suri spoke about new frontiers in the treatment of PE and outpatient management in low risk populations (1, 2, 3, 4, 5)
  • There was a talk on ED ‘super-utilizers’ and the push for aggressive, individualized social work and care coordination.  Good read… “The Hot Spotters
  • Critical care pearls for managing the morbidly obese
    • Forearm BP cuff measurem
      ents correlate well with actual arterial pressure, while upper arm cuff measurements are unreliable
    • Dose lipophilic drugs based on ACTUAL body weight and non-lipophilic drugs on IDEAL body weight.  In addition, ventilation should be based on IDEAL body weight
    • Here’s an article by our very own Dr. Doug Brunette, “Resuscitation of the Morbidly Obese Patient” in AJEM from 2002.  Not #FOAMed, but if your institution gives you access to this journal, it’s a great read
  • Rocky Mountain Poison Control Center docs spoke about synthetic cannabinoids and have reported many pediatric admissions after ingestion of edible versions
  • More and more research on opioid prescription registration programs is happening, with a push for a national opioid prescription database.
  • EGDT and the ProCESS Trial were discussed, showing that early identification and aggressive management of the septic patient saves lives
  • There were many talks on honing teaching skills this year with a cautious but optimistic trend in using social media and #FOAMed as an adjunct for medical education

Final Thoughts

I was pleasantly surprised by how much fun we had at SAEM and how rewarding it was to go as an intern.  There is so much excitement and energy in the EM community when it comes to advancing the specialty and improving patient care.  Listening to the leaders in our field talk about their passions motivates young residents and encourages us to dig deeper into the hot topics being discussed.  It also pushes us to discover our own passions and develop our niche in Emergency Medicine.

As we cheered on our co-residents who presented their research to panels of experts, we were inspired to take an active role in research in the coming years.  In fact, of all the Hennepin residents who attended SAEM this year, over two thirds said that they were much more likely to ask our faculty to help with their research or to present an abstract in the future.  This was obviously a very statistically significant poll with lots of p-values and confidence intervals, but it does show that in addition to all the awesome lectures, networking with faculty, and socializing with other residencies, there is a real benefit to going to academic conferences early in our careers.

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The LITFL Review 138

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.

Welcome to the 138th edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

 We all have to deal with the challenges that society throws at us everyday whether we are in ED, ICU or the operating room. We all approach these challenges differently. Some of us internalise it, others talk to a mate about it, but a lot of us joke or even swear about these encounters as a means of coping. Liz Crowe gives an amazing talk at smaccGOLD - swearing your way out of a crisis - and delves  deep into this often taboo and politically incorrect approach we take to these situations. [KG]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMPed Paediatrics

#FOAMTox Toxicology

News from the Fast Lane

  • Rick is back at his best with The Land of Protocols - whether we like it or not- protocols are becoming more and more common down under! [KG]
  • R & R in the fast lane is back…..Yay! Anand Swaminathan, Nudrat Rashid, Jeremy Fired ans Soren Rudolph have joined the LITFL team to produce the 32nd Research and Reviews in the FastLane. [KG]

LITFL Review EM/CC Educational Social Media Round Up

Emergency Medicine and Critical Care Blogroll — Emergency Medicine and Critical Care Podcasts — — Academic Life in Emergency Medicine — A Life at Risk — Bedside Ultrasound - BIJC — Boring EM — Broome Docs — CCM-L — Critical Care Perspectives in EM — Dave on Airways — Dont Forget the Bubbles — Dr Smith’s ECG Blog — ECG Academy — ECG Guru — ECG of the Week — ED ECMO — ED Exam — ED-Nurse — EDTCC — EKG Videos — EM Basic — EMCrit — EM CapeTown — EMCases — EMDocs — EMDutch — EMin5  Emergency Medical Abstracts — EM Journey — EmergencyLondon — Emergency Medicine Cases — Emergency Medicine Education — Emergency Medicine News — Emergency Medicine Ireland — Emergency Medicine Tutorials — Emergency Medicine Updates — EM on the Edge — Emergucate  — EM Journey —  EM IM Doc — EM Literature of Note — — EMpills — Emergency Physicians Monthly — EM Lyceum —EM nerd— EMProcedures — EMRAP — EMRAP: Educators’ Edition — EMRAP.TV — EM REMS — ER CAST — EXPENSIVECARE — Free Emergency Medicine Talks — Gmergency! — Got Resuscitation— Greater Sydney Area HEMS — — Impactednurse —Injectable Orange  — INTENSIVE — Intensive Care Network — iTeachEM — IVLine — KeeWeeDoc — KI Docs— ER Mentor — MDaware — MD+ CALC — MedEDMasters — Medical Education Videos — Medical Evidence Blog — MedEmIt — Micrognome — Movin’ Meat — Paediatric Emergency Medicine — Pediatric EM Morsels — PEM ED — PEMLit — PEM Cincinnati — PHARM — Practical Evidence — Priceless Electrical Activity — Procedurettes — — Radiology Signs — Radiopaedia — REBEL EM - — Resus.ME — Resus Review — RESUS Room — Resus Room Management — Richard Winters’ Physician Leadership — ruralflyingdoc — SCANCRIT — SCCM Blogs — SEMEP — SinaiEM — SinaiEM Ultrasound — SMART EM — SOCMOB — SonoSpot — StEmylns — Takeokun — thebluntdissection — The Bottom Line — The Central Line — The Ember Project —The Emergency Medicine Resident Blog — The Flipped EM Classroom — thenursepath — The NNT — The Poison Review — The Sharp End — The Short Coat — The Skeptics Guide to Emergency Medicine — The Sono Cave - The Trauma Professional’s Blog —  — ToxTalk — tjdogma — Twin Cities Toxicology — Ultrarounds — UMEM Educational Pearls —Ultrasound Podcast

LITFL Review

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