284 Emergency Medicine
patient with an intact gag reflex.The nasal airway is an excellent device
that can be placed in a patient who may have decreased pharyngeal muscle
tone and an obstructing soft palate and tongue. It allows air to bypass such
obstructions. The patient in the vignette is intoxicated and appears to have
episodes of transient obstruction.
(b)An oral airway is a rigid instrument that is used to prevent the base
of the tongue from occluding the hypopharynx. It should be used to main-
tain the airway only in a patient with an absent gag reflex. (c)Bag-valve-
mask ventilation is typically used to oxygenate a patient in preparation for
a definitive airway, such as orotracheal intubation. (d and e)Laryngeal
mask and tracheoesophageal and airways are devices typically used in the
ED as rescue devices in failed intubation or in the prehospital setting when
orotracheal intubation is not a viable option. These devices are designed to
be placed in apneic, unconscious patients.
255.The answer is a.(Tintinalli, p 1307.)Profound hyperglycemia,
absence of ketonuria, and diabetes medication noncompliance should raise
your suspicion for nonketotic hyperosmolar crisis (NKHC)in this patient.
This condition is a syndrome of hyperglycemia without ketoacidosis as small
amounts of insulin protect against adipose tissue metabolism. This syndrome
is more common in type 2 diabetics. Causes of NKHC are similar to those of
DKA and include diabetes medication noncompliance, infection, stroke,
and myocardial infarction (MI).Patients are profoundly dehydrated because
of osmotic diuresis. The mainstay of NKHC therapy consists of replacing fluid
losses.Electrolyte deficiencies should be replaced and insulin administered.
Fluid deficit in NKHC is significant and needs to be slowly corrected, as rapid
correction may lead to cerebral edema. Insulin requirements in NKHC are usu-
ally less than in DKA.
Further diagnostic tests are important to obtain, depending on the
patient’s presentation and suspicion of an underlying etiology of NKHC. In
this case, medication noncompliance is most likely. In other cases, head CT
for workup of intracranial pathology (b), ECG for evaluation of MI (c), or
chest radiograph and urine culture for infectious etiology workup (d)might
be necessary. Without an infectious etiology, broad coverage antibiotics
(e)are not necessary in this patient.
256.The answer is b.(Tintinalli, p 1283.)This is a case of hypoglycemia
as a result of oral hypoglycemic medication overdose. Diabetic oral agents
that cause hypoglycemia work by increasing pancreatic insulin secretion.