528 Emergency Medicine
illness. Osmotic diuresis is even more pronounced than in DKA. Rapid cor-
rection of hyperosmolar state may lead to cerebral edema. Unlike DKA, acidosis
and ketosis are usually absent or minimal. The mainstay to treatment is fluid
resuscitation, insulin administration, electrolyte repletion, and searching for an
underlying precipitant.
(b)Phenytoin is contraindicated for seizures in HHNC because it is
often ineffective and may impair endogenous insulin release. (c)Fluid
resuscitation is the mainstay of treatment and should always be adminis-
tered prior to insulin. (d)Although the patient may ultimately receive a CT
scan, fluid resuscitation is priority because of the profound dehydration in
these patients. (e)If a patient has functioning kidneys, hemodialysis is not
necessary. However, if the patient has end-stage renal disease, then hemodialy-
sis may be necessary to treat over hydration.
479.The answer is c.(Rosen, pp 1750-1754.)The triad of hyperglycemia,
ketosis,andacidosisis diagnostic for DKA.All abnormalities in DKA are
connected and are based on insulin deficiency. When hyperglycemia sur-
passes the renal threshold for resorption, glucose is excreted in the urine.
This causes an osmotic diuresis which in combination with decreased oral
intake and vomiting leads to dehydration and electrolyte abnormalities.
Cells, unable to receive glucose from the circulation, switch to starvation
mode by increasing proteolysis. The liver starts producing ketoacid subse-
quently causing acidemia. The acidotic patient increases RR, in an attempt to
blow-off excess carbon dioxide, and bicarbonate is used up in the process.
(a)Hypotension, tachycardia, and tachypnea are commonly seen in
DKA but are not specific for the condition. (b)Leukocytosis is seen in many
other conditions other than DKA. (d)Although a fruity odor to breath may
suggest acetone, a product of ketone production, it is not reliably present
and difficult to distinguish. (e)Glucosuria is present with hyperglycemia.
Ketones are required for DKA.
480.The answer is a.(Tintinalli, p 1287.)You should be suspicious for
DKAas the initial presentation of diabetes mellitus in this patient. Glucose
levels are elevated, typically greater than 200 mg/dL. DKA is an acute, life-
threatening disorder occurring in patients with insulin insufficiency(more
common in type 1 diabetes) and results in hyperglycemia, ketosis,and
acidosisfrom osmotic diuresis leading to dehydration and acidosis. This
patient exhibits classic signs and symptoms of DKA, such as tachycardia, GI
distress, polyuria, polydipsia, fatigue, and confusion. Very deep breathing