This is the first in a series from Susan Dupont RN BSN who is an Emergency Room Nurse and contributor at NRSNG.com . . . Click to View All Articles in the “Real Life in the ER Series”
Every patient is a mystery that needs to be solved. Some are easy, some are complex, some aren’t solvable, but the thrill of a good challenge is what keeps me coming back for more. The emergency room is full of unsolved mystery’s. Every once in a while a mystery worth writing about comes along.
It was like any normal shift. I had just discharged a patient and walked them out of the ER to turn around and see an EMS stretcher waiting to enter my room.
I hadn’t even cleaned the room yet. I grabbed a piece of paper and pen and walked into my favorite type of patient, Altered Mental Status.
This patient, a 20-year-old female, had been found wandering around the streets and stumbling around. She didn’t know her name and when she attempted to talk, random words were coming out of her mouth. She would only respond to a sternal rub and her breath was fruity.
Vital signs:
- BP 80/48 mmHg
- Respirations of 32
- Heart rate 125 bpm ( sinus tachycardia on her EKG) .
After getting a reading of >500 blood glucose on the glucometer, we started the search for an IV. This was the challenge of the night. This little girl had absolutely tiny veins that were hidden.
Her first IV gave us blood but after starting a bolus of normal saline the line infiltrated, causing a grape sized lump on her forearm.
The next IV was in her hand and it worked but was only a 22 gauge. We needed better IV access. After using the infrared goggles and ultrasound we got 2 IV’s, one in each antecubital. Suspicious of Diabetic Ketoacidosis, her lab work confirmed the diagnosis.
Her blood work showed:
- Glucose of 956 mg/dl
- K+ 5.8 mEq/L
- Cl- 110 mmol/L
- HCO3 of 9 mEq/L
- Arterial pH of 6.9
Her Urine was positive for:
- Ketones
- Glucose
- With a specific gravity of 1.030.
We implemented the DKA protocol starting an insulin drip, fluid boluses/Potassium, and a Foley that filled faster than I could empty it.
It was all going as planned so of course one of her IV lines infiltrated giving her a grapefruit sized lump on her skinny arms. Multiple of our best staff members looked for a second IV line for about 30 minutes, we decided on the External Jugular vein.
Things seemed to be back on track and she was starting to come around, opening her eyes and saying one word very clearly, “Water.”I gave her 5 pitchers of water and she sat there drinking the water with extreme intensity.
Somebody Help!
She finished all five pitchers of water in about 45 minutes and asked for more, I walked out of the room to get her more water and before I hit the nutrition room, I heard another patient shout, “Somebody help!”
I turned around to see my patient standing at the door of her room with blood dripping down her neck and arm with fluids everywhere. She had gotten up out of her bed and walked to the doorway, causing all her IV’s to rip out and the cardiac monitor lines to become detached.
Some how, of all the things to stay intact, she still had her Foley in place, with the bag dragging on the ground. I grabbed gauze and ran to her to stop the bleeding from her latest pair of IV’s and walked her back to her bed.
The four bags of normal saline that were hanging with pressure bags around them had created a small lake on the floor mixed with blood. It was quite a scene.
Despite the series of unfortunate events with this patient, she will probably be one of my favorite patients because that day, there weren’t any ICU beds available and, having this patient for my entire shift, I got to see the end result of my work, which is normally done on the floor. She was alert and oriented with her blood glucose stable, her anion gap had closed, and I was able to discontinue her IV medications and transition to subcutaneous injections.
Need help understanding DKA?:
The key to understanding how to treat DKA is in the science. DKA occurs in people who are not controlling their blood glucose levels. Having high blood sugar means that your cells are not receiving the sugar, instead, it is just in the blood. Sugar is the fuel that keeps our cells going, so if we starve our cells of sugar, they start to break down fat to get the sugar.
The problem with that is that the chemical break down of fat leaves ketones. Ketones are acidic leaving your blood in an acidotic state.
Our bodies delicate systems cannot perform under acidic environments thus processes like metabolism become altered. To help the body correct this acidotic state, you need to focus on something called the anion gap.
The anion gap is a measurement of the gap created between cations (sodium and potassium) and anions (chloride and bicarbonate). The goal is closing the gap. Administering insulin will allow the sugar to go into the cells. Insulin will also pull in potassium so it is important to administer potassium along with lots of fluids to increase the hydration status of the patient. Fluids also help to flush out the ketones. Eliminating ketones, closing the anion gap, getting the blood glucose within normal limits, and hydrating your patient is how you save a patient in DKA.
