Emergi-Press: Case from The Field – AUGUST Issue

EMS confirms that the initial dispatch call was for “trouble breathing, confusion and vomiting”.  Further history is obtained from the sister who made the call.  The sister states that the patient has been sick for the last week.  She is usually healthy. Initially she just felt weak and rested at home but was vomiting and feeling worse, so she went to a clinic 4 days ago.  At that visit, she was having a runny nose, vomiting and breathing fast and was diagnosed with an URI.  She was told to rest at home and stay hydrated.  The sister has been encouraging her to drink fluids but called 911 today because she was vomiting more often, always thirsty, breathing very fast, and seemed confused.  The patient was not as responsive as usual when she woke up this morning.  The patient describes that she has been under a lot of stress at school.  She says she feels “really anxious” and believes that is why she is breathing so fast.  She appears awake and alert.  Repeat vital signs are BP 112/70, HR 120, RR 26, O₂ Sat 99%

Despite the patient attributing her symptoms to being “anxious” she is still tachycardic and tachypneic.  The sister also describes concerning symptoms of vomiting, difficulty breathing, and transient confusion.  She requires a full head to toe assessment, including lung and abdominal exam, as well as her perfusion status.  Further history should be obtained for any known past medical history the patient may not have mentioned.

Provider Impression considerations include:

Respiratory Distress Other (RDOT) – she was recently diagnosed with a URI which may have progressed to pneumonia

Sepsis (SEPS) – a recent infection or pneumonia can progress to sepsis

Nausea/Vomiting (NAVM) – she has been vomiting; what is the underlying cause?

Abdominal Pain/Problems (ABOP) – is her vomiting associated with an abdominal condition (e.g. appendicitis, gastroenteritis)?  Does she have a tender abdomen?

Hyperglycemia (HYPR) – Hyperglycemia can cause confusion.  Undiagnosed diabetes can initially present with diabetic ketoacidosis (DKA) which can have vague symptoms, including abdominal pain, vomiting, and excessive thirst. DKA also leads to rapid, deep breathing (Kussmaul’s respirations) due to the metabolic acidosis.

Hypoglycemia (HYPO) – Hypoglycemia can cause confusion and generalized weakness.

Pregnancy Complications (PREG) – is the patient pregnant?  Pregnancy can cause nausea and vomiting as well as general malaise. Pregnancy associated emergencies, like a ruptured ectopic pregnancy, can cause blood loss which would lead to tachycardia.

Behavioral/Psychiatric Crisis (PSYC) – the patient may have anxiety, but this is a diagnosis of exclusion.  Her abnormal vital signs should prompt concern and determination of an underlying cause at the hospital.

When specifically questioned about other symptoms, the patient denies any other past medical history or being pregnant.  She has not had fevers or cough.  She has had vague abdominal pain, nausea and vomiting.  She has been very thirsty (polydipsia) and has been urinating more frequently (polyuria).  When she was seen at the urgent care, no blood work or urine testing was performed.

On physical examination, her mucous membranes appear dry.  Her lungs are clear, abdomen is soft and non-tender.  She has delayed capillary refill, poor skin turgor and appears pale.  She remains tachycardic and tachypneic.

Her glucose is checked and reads critical “HIGH”.

This patient is in diabetic ketoacidosis (DKA), a hyperglycemic diabetic emergency.  Her provider impression is Hyperglycemia (HYPR) and she should be managed in accordance with TP-1203, Diabetic Emergencies.

Even though the patient has no known history of diabetes, the initial presentation of diabetes can be DKA, especially in children and young adults.

Her glucose is > 400 mg/dL, reading HIGH, and she has signs of poor perfusion.  Administer Normal Saline 1L IV rapid infusion.  Ondansetron 4mg ODT/IV/IM can be given for her nausea and vomiting.

While this patient is young and previously known to be healthy, be cautious when patients present with “anxiety”. Anxiety as a symptom is commonly encountered in the field and in the emergency department, and may be a reaction to a serious underlying medical problem.  Determining that the anxiety is due to a primary behavioral/psychiatric condition should be a diagnosis of exclusion – you have considered other pathophysiological causes of the patient’s history, signs, and symptoms, before determining that they are due to a primary psychiatric cause.

This patient could have easily led the paramedics astray as she attributed her own symptoms to anxiety and school stressors.  Recognizing abnormal vital signs and the overall patient presentation led to more investigation being performed (a point-of-care glucose, in this case), which revealed the underlying cause.

DKA is a serious, life threatening condition that can occur in diabetics^1,2.  In DKA, the patient does not have the insulin required to absorb glucose into cells and use for energy.  Because the body can not absorb and use glucose, the body goes into a starvation state.  Three physiologic syndromes occur in DKA:

1. Metabolic acidosis – the inability to utilize glucose causes a “ketoacidosis”. Ketones are metabolic byproducts that are produced due to the breakdown of fat (ketones) for energy.  The patient will have a metabolic acidosis and will breath rapidly to compensate.  This breathing pattern is called Kussmaul respirations (see previous Diabetic Complications Emergipress Video).  Much like other causes of metabolic acidosis, including sepsis, patients that are compensating for their underlying metabolic acidosis with rapid respirations will likely have a low EtCO₂. Though more studies are needed to determine if a EtCO₂ <25  can be a reliable measurement to predict DKA in hyperglycemic patients, an association was found in a recent study³.
2. Osmotic diuresis – because of the high level of glucose that is filtered through the kidneys, the patient will have an osmotic diuresis and urinate frequently. Glucose has a high osmolarity. Above a certain level, glucose “spills” into the urine and water follows by osmosis.  Patients in DKA will have symptoms of frequent urination with excessive thirst (i.e., polyuria and polydipsia) and will be dehydrated.
3. Electrolyte abnormalities – losses of large amounts of fluids and acidosis can lead to imbalances in sodium, potassium and other electrolytes.

DKA can be the first presentation for a patient with type I diabetes.  This is most common in previously healthy children and young adults that have vague complaints of feeling week or tired, and are always thirsty.  The 4 T’s: drinking constantly (Thirsty), being Tired, losing weight (Thinner), and urinating frequently (Toilet) are common symptoms.  Because the symptoms can be vague and not elicited if not specifically asked for, the diagnosis can go unrecognized, even by medical providers.

DKA is an emergency that will result in death if left untreated.  The patient will experience volume loss which can lead to hypovolemic shock.  The profound metabolic acidosis will lead to cardiac arrest if left untreated.  DKA initially develops over several days but can progress rapidly once the patient becomes symptomatic.

MS recognizes that the patient is in DKA after obtaining a blood glucose.  Normal Saline is administered as well as ondansetron.  EMS confirms that the patient had no known diagnosis of diabetes and that this is her first known episode of hyperglycemia.  She is rapidly transported to the Most Accessible Receiving (MAR).

In the Emergency Department, the patient is diagnosed with DKA.  Fluid resuscitation is continued and the patient is placed on an insulin drip.  She is admitted to the ICU.

1. Abnormal vitals signs must be recognized as they may be a sign of serious underlying diagnosis, especially for patients with vague complaints.
2. DKA can present subtly with vague symptoms and is often the first presentation of diabetes in children and young adults. Check a glucose when the patient presents with concerning symptoms, even when a diagnosis of diabetes has not been established previously.
3. DKA is a life threatening condition that must be recognized and treated emergently.
4. Anxiety is a diagnosis of exclusion. Patients often feel “anxious” when they have a serious underlying medical condition.  Perform a complete assessment, particularly paying attention to abnormal vital signs.