Altered Mental Status Answers 283ketosis, and osmotic diuresis and clinically presents with gastrointestinal
(GI) distress, polyuria, fatigue, dehydration, mental confusion, lethargy, or
coma. When the diagnosis of DKA is clinically suspected and hyperglycemia
is confirmed by elevated fingerstick glucose, the results of a blood gas and
urinalysis confirm the diagnosis. In DKA, the liver metabolizes free fatty
acids into ketone bodies for alternative fuel in the setting of cellular glucose
underutilization. The result is ketonuriaandanion gap metabolic acido-
sis (pH < 7.4 and HCO 3 < 24). Glucosuria,the result of hyperglycemia-
related osmotic diuresis, is another manifestation of DKA.
The anion gap is calculated by subtracting Cl−and HCO 3 −from Na+.
Anion gap (AG) = [Na+]−([Cl−] + [HCO 3 −])A normal anion gap is 8 to 12 mEq/L. An elevated gap is a result of an
increased concentration of unmeasured anions. In DKA, the elevated anion
gap is caused by the production of ketones.
Other answers (a, b, c, and d)are incorrect choices in the DKA
presentation.
253.The answer is d.(Rosen, pp 1748-1750.)In a patient who is actively
seizing,it is essential to check the blood glucoselevel.Hypoglycemiais
an easily reversiblecause of seizure and is corrected with the administra-
tion of dextrose, not the usual anticonvulsants. Patients at both extremes
of age are particularly susceptible to glucose stress during acute illness.
If the blood glucose level is normal then requesting a rectal temperature
(a)is appropriate. However, this should be done concomitantly with address-
ing airway protection, gaining IV access, and administering an anticonvulsant.
A CT scan (b)may be necessary in a seizure patient; however, this should
occur once the patient is stabilized. An ECG and aspirin (c)is usually the ini-
tial management for patients with chest pain. In an actively seizing patient,
nothing should be administered by mouth because there is an increased risk
for aspiration and the patient may not have a gag reflex. Intubating (e)the
patient may be necessary if the seizure cannot be medically controlled, the
patient is hypoxic, or not protecting his or her airway. In the above patient,
you’d expect the seizure to cease once glucose is administered. In addition,
her oxygen saturation is 96%.
254.The answer is a.(Tintinalli, pp 103-104.)Anasal airwayis made of
a pliable material that allows it to be placed into the nostril of a somnolent