DIP Episode 98 - USMLE Step 3/Medicine ITE/ABIM Review Series 4 (Diabetic Emergencies)

Okay, welcome to the 98th episode of the Divine Intervention Podcast. My name is Divine. I am a PGY1 Transitioner, your resident that's going into radiology. Into this podcast, I guess I'll just go ahead and foreshadow this little warning. Whatever our views I express in this podcast does not reflect the views of any residency program I am involved with or will be involved with. But today's podcast will basically be a step three or we can see like medicine in training exam or medicine board exam review. And to this topic is going to be about the management of DKA or HHS. Those are both diabetic emergencies. So let's jump right into it. So we know that diabetes can have multiple complications and probably one the most serious ones, right? Like DKA and HHS. DKA Classically the blood glucose is less than 800 but I will encourage you to not hang your head on that number. Especially for purposes of test taking because the thing is on tests, you may see a blood glucose that is higher than 800 but they have like ketosis, right? And that still will be a diagnosis of DKA. So I would go based on the presence of ketosis or acidemia to help you deal in need between DKA versus HHS. Well, classical patients with HHS they have more higher blood glucose levels versus patients with DKA that tend to be on the lower side of things usually less than 800. So these things can arise for many different reasons. Echan arise in the setting of like a new diagnosis of diabetes.

Echan arise in the setting of a patient that's not compliant with their home medications or they run out of their meds. Those are classic ways these things happen like clinically in the hospital. So if a patient comes in with DKA or HHS, right? Obviously you're going to obtain labs, right? And classically the patient will have like polyurea, polydipsia. They will basically feel pretty crummy, right? And you get labs and if you're dealing with DKA again the glucose will be pretty high, right? And then in addition to that, they'll have all the electrolyte abnormalities, right? So their bicarb will be low showing that they're acidotic. They'll have a pretty significant ketosis, right? So you can detect the ketones in their blood, especially like beta hydroxybutyrate and you'll detect the ketones in their urine as well. And those patients, especially with DKA ears and patients with HHS, they tend to have hypoinitremia, right? But it's a pseudo hypoinitremia, right? So it's like a hyper or smaller hypoinitremia, right? And you probably want to know how to do the correction for things like this. And again, forgive my arms and arms. I'm literally giving this off the cuff. But basically, say for example, you have a patient with a blood glucose of like a thousand, right? So let's use 900 as a cutoff value. Basically the way I figure out and let's say their blood glucose in the hospital is 120, what I typically do is I subtract the hundred from their blood glucose.

So in this case, it'll be 800. And then ask myself, how many hundreds is that? Right? So that is 800, 100, right? So it's like 800, right? By 100 is eight. And then I take that if I multiply by 1.6. So 1.6 times if I believe is 12.8. So we can round that up to 13. So this patient's true blood glucose, if it's 120 in the hospital, it's actually 133. Okay? And obviously the way you treat that kind of hyper or smaller hypoinitremia is to treat the underlying condition. In this case, DKA or HHS. And then patients with DKA, right? They can also have potassium problems, right? So the BB hyper, Kelimic, on the labs, but their total body potassium is actually depleted, right? And the reasoning behind that is because they are peanut ton, right? So they are peanut a lot of potassium. And HHS basically it's pretty much the same presentation as DKA. Only thing is patients with HHS tend to be a lot more volume depleted. They can be like up to 10 liters volume down. And then in addition to that, they do not have the acidemia on labs. They do not have the ketosis. So that's the classic, those are the classic things you want to think about with a DKA versus a HHS. But the treatment is largely the same for both. There are some like minute differences, but the treatment is largely the same. So basically the first thing you do is fluids, right? You need to start those patients on fluids. And the fluid that you typically start with is lomo-sealing, okay? You start with lomo-sealing.

And classically, at least as per the guidelines, you can start with like a liter an hour of lomo-sealing. You can do that for like a few hours, right? So maybe like two hours, three hours, right? So you give them probably up to like three liters or they're about depending on how volume down they are. And then after that, you can then begin to think about instead of doing normal saline, you can then switch to half normal saline. And I'll talk about certain decisions you can make on that those are circumstances. And at the end, I will try to sort of like summarize the saline points of from this podcast. But basically, you, so you, you, you worry about your fluids and then other things you worry about are you worry about their insulin, right? And their insulin, right? Typically, you give them a bolus first and classically, what I do when I'm in the hospital or what the guidelines sort of suggest is like 0.1 units per kilogram, right? So see, for example, you have a 100 kilogram patient, right? If you're given 0.1 units per kilogram, you can give a bolus of 10 units, right? Because 0.1 times 100 is 10. So you give that bolus. And the bolus is regular insulin, right? So like insulin regular. And then after that, you start them on an insulin drip, right? So like an insulin infusion, basically. And again, the infused insulin is also regular insulin. And again, you started a rid of 0.1 units per kilogram per hour, right?

So see, for example, it's a patient that has that's in a, that again, has a weight of 100 kilograms, 0.1 units per kilogram per hour. That's like 10 units per hour. That's what you're supposed to do for the guidelines, right? But classically in the hospital for myself, so that's just again, these are all my opinions, just not reflect the opinions of anyone. But classically, I tend to under shoot a little, I am erm on the side of start low and go high, then start really high, and then make the person high, like see me, right? So start low. So I mean, started like small number like five units per hour stuff like that. And then just see, if the patient's blood glucose is not dropping by like 70 milligrams per deciliter every hour, then you can type trade upwards. But if you start them at a low amount and you're clearing like 50, 70 milligrams per deciliter, that is good enough glucose, that's a good enough glucose fix on that little circumstances. So again, insulin, you start with a ball of regular insulin, 0.1 units per kilogram. And then after that, like minutes later, you study on an insulin infusion at 0.1 units per kilogram per hour, okay? And then you also have to think about the potassium, though, right? So if a patient with with indecil HHS has a potassium less than 3.3, you should not start insulin on that little circumstances. You need to wait until the potassium goes above 3.3 before you can start giving insulin.

And when the potassium is between 3.3 and 5.3, you actually are advised to add potassium to whatever fluid they're getting, right? So if for example, they're getting a normal ceiling for every leader, it is recommended that you add like 20 million equivalents of potassium to every liter of fluid that they're getting, if their potassium is between 3.3 and 5.3, if their potassium is above 5.3, you do not need to necessarily need to add potassium to their to their fluids. So you start your insulin regimen, your pain attention to the potassium, your pain attention to their fluids, the asserting things you want to keep at the back of your mind, right? So say for example, you've done that initial bolus of fluids, let's say you give them like, you're giving them like three, one liter normal ceiling boluses, the next decision you make, usually the next decision you try to make is to switch them to half normal ceiling, right? So like 0.45% normal ceiling. But you have to sort of do a certain cow, at least this is how I think about it, you make a certain calculation before you go down the route, right? And the calculation you make is basically calculate the corrected sodium. If you calculate the corrected sodium using the formula exposed on at the beginning and they are normal or hypermetrymic, then you can go ahead and immediately switch them to half normal ceiling to 0.45% normal ceiling. But if they are high poor nitrimic, even with the corrected sodium.

So let's say you calculate the corrected sodium and it's like 131, I would elect and the guidelines indicate that you should consider continuing those people on normal ceiling instead. But the thing is the rate you continue at is typically about 250 cc's per hour. Again, if the patient is more volume down, you can start at a higher rate, but you can do like 250 cc's per hour and that should tidy the patient over. That's like getting a litter over a four hour period. But again, note that this is after that initial bolus. You need to give that initial bolus of like two liters or thereabouts to sort of like tidy them over. Okay, now so you give you start the insulin, you start the potassium, you start the insulin infusion. Another thing you can also think about is the acidotic state. So say for example, if a person has a pH of like 6.9, what some people think about is you know what should I add by carp? The thing is it's very controversial. Usually if you treat the decay of the HHS, the acidemia typically results. So you very really need to give a decay person by carp. But if you do, I'll say in general, people do it only when they have like pH of 6.9 and it's not correct enough to have a few hours of studying like an insulin infusion. And some of you may ask divine, why would the people that are a bit in decay or HHS require the volume? Why are you giving them all this fluid?

The reason you're giving them the fluid is that by giving the fluid, right, you are beginning to volume one, I mean they've been peanut toned, right, because they've been polyureic, right. So by giving the fluid, you correct the volume deficits. And the thing is as you correct the volume deficits, that actually sort of like makes them hemodynamically stable, right. And remember, right, when you're like volume down, your body is interprets that as stress. And when you're body interprets that as stress, it begins to release counter-regulatory hormones like cortisol. So if you're beginning to expand the volume, your body is like, oh, my stress is decreasing. So if your body is like, oh, my stress is decreasing, your body will stop releasing those counter-regulatory hormones like cortisol. And if it's not releasing cortisol anymore, guess what happens? Remember cortisol makes you hyperglycemic, right? You are basically removing a hormone from play that makes you hyperglycemic in the first place. And there are many other things, the volume expansion does, but that is beyond the scope of our discussion today. So you keep managing the patient. And again, your target is right to try to get their blood glucose down by like 50 to 70 milligrams per deciliter every hour, okay. If your, if the patient's blood glucose is going down like by huge amounts like 200 makes per deciliter per hour, then you want to be careful. You sort of want to turn down that insulin infusion.

So let's say it's like a rate of five minutes per hour. You probably want to go ahead and drop it down to like two minutes per hour, right? And then titrate as needed, right? You don't want to plump the person's glucose down too much. Remember, from one of my earlier podcasts I mentioned that you don't want to correct any electron ed and anomaly too fast, right? So you don't get into trouble. So certain key points you sort of want to put at the back of your mind is while you're doing all these things, you also have to actually like monitor the patient, right? So classically, if a patient is in DKA or in HHCNS, the guidelines actually recommend that you do like one hour glucose checks. So every hour you check the blood glucose, okay? Because remember that blood glucose is what guides a lot of the decisions that you can make in the setting of DKA or HHCNS. And then you can also, you should also check a BMP fairly frequently, right? So again, most people recommend checking every two to four hours. Although again, all of this, I'm saying this mainly for the purposes of exams. I mean, this will probably help in your clinical world, but again, these podcasts are not meant for clinical decision making. Even if they may help you with clinical decision making, that is not the goal. That is not the purpose. I'm not making any of those promises. But I will just go ahead and posit that it depends on your hospitals, philosophy.

The hospitals have seen where BM Ps and check every eight hours, some every four hours, some every two hours, okay? But the guidelines, the things you need to know, for example, say try to check it every two to four hours. Now, so let's go to an important, I guess, a point in this entire process, right? So if we get to, let's look at the person that has decay, if a person has decay, right? And their blood glucose dips below 200. If it gets to 200 or and they're, yeah, if it gets below 200 and their gap closes, so basically if they are anion gap, sort of goes below 12, right? Then they're basically beginning to come out of the woods. But the thing is, when their blood glucose dips below it also marks an important transition point in your therapy, right? When the person's blood glucose drops below 200, the next step in management on an exam is a pretty common exam question, is to go ahead and add the dextrose to their regimens, right? So based solely on the glucose, glucose 200 or less for a decay person, go ahead and add a dextrose to their regimen, right? Because remember, they are having an insulin infusion, you don't want them to become hypoglycemic. In the case of a person that has HHNS, if their blood glucose is between 250 to 300, that is also where you want to go ahead and add dextrose to their, basically to the fluids they're getting to the 0.45% cell that they're getting. Now, at that, in the case of a person that has decay, right? When their gap closes, right?

So the gap is defined as closed if it drops below 12, right? So you can leave the anion gap. If it drops below 12, that tells you their gap is closed. If the gap is closed, at that time, you can then go ahead and start those patients on subcutaneous insulin, right? So like the basal bolus insulin. And I'll talk about how you approach that particular problem, right? So you can go ahead and start the abyssal bolus insulin if you're diabetic and you're on insulin outside at home, right? You usually can start them on the home regimen and that but if the insulin naive, I'll talk about what you do under those circumstances. So basically, you do the basal bolus regimen, but the thing is, when you're studying that basal bolus regimen, you do not immediately turn off the insulin infusion, okay? Because the thing is, if you turn off the insulin infusion immediately, right? Remember, it's an infusion, you're giving this IV. The bioavailability is like 100%. If you turn off the insulin infusion, you can actually get like a rebound hyperglycemia and you can actually throw them right back into decay. So you do not want to do that. Under those circumstances, right? So when you hear that magic, like, oh, the gap is closed is 12 or less. The anion gap is 12 or less. Start the subcutaneous insulin, right? But when you start that subcutaneous insulin, remember that you need to keep that going for two hours before you then go ahead and turn off the insulin infusion, okay?

So they should basically be like a two hour overlap between when you start the insulin, I mean, the subcutaneous insulin and when you turn off the insulin infusion, right? And I said that, oh, the trigger for knowing that, okay, let me go ahead and start subcutaneous insulin in a decay person is, if the gap closes, the trigger for you to go ahead and start subcutaneous insulin, HHS person is if the glucose is below 250, okay? And the patient is demanding food. Basically, if the patient is ready to eat and the glucose is 250 or less, you can go ahead and start subcutaneous insulin. Now, and remember, right? Your subcutaneous insulin is like the long actin that you give, like, usually once a day and then the rapid actin that you give with meals. Okay. So I said that when you start that subcutaneous insulin, you basically start the home regimen, right? So you start them on the long actin, start them on the rapid actin with meals. But let's assume it's a patient that's insulin naive or you're like, um, divine, I don't really know what to do here. One thing you can actually consider is to start them at, so basically what you can do is you can calculate the total daily requirement of insulin, right? So one way you can do that is you can pick a conservative number. Um, the guidelines say that you can consider like 0.5 units per kilogram, right? So again, I love to give people like actual numbers. So let's assume you have a patient that is 120 kilograms.

0.5 units times 120 kilograms is 60 units, right? So basically, those patients, the total daily insulin requirement is 60 units. The next thing you do is to divide that number in two. So 30 units in one portion, 30 units in the other portion. The first number, 30 units is what they should get as the long actin, right? So long actin, you get 30 units, maybe like, lunch in 30 units at night. And then the other 30 units, you basically divide that into the number of meals they get in a day. Most people eat three times a day, right? So you can say, you know what? I'll give you 10 units of insulin with each meal. That is what you can do for an insulin, naive person or a person where you're not very sure of the home insulin regimen. But again, the thing is you want to be careful, right? You want to be careful. Uh, that is what the guidelines indicate. But in the real world, personally, if I'm studying a patient like an insulin, naive patient, again, I always try to go low first. I don't, uh, but the 0.5 units per kilogram is usually a pretty safe number to go with. But if let's say you make the calculation is an astronomical number, like 200 units or like something crazy, I mean, I will be very suspect of studying a person like 100 units of long actin insulin at night. I would err on the side of studying small, right? Start at a small reasonable number, right? That you feel comfortable with and then sort of go from there. But that 0.5 units per kilogram is a good safe number.

You can sort of keep at the back of your mind if you're scared and you get like super high numbers from that calculation. Maybe go ahead and half that number to like 0.25 units, okay? But again, I will leave that up to your own clinical decision making or your own hospitals or policy. Again, this podcast is mainly to prepare people for tests. Okay. So that is, that is basically what you, that's basically what you do. That's essentially how you manage decay or HHCNS, right? And remember, right under those circumstances, you want to tell the patient, you know, stick with your insulin regimen, check your blood glucose regularly. Because again, medigational compliance is probably one of the more, I'm not saying the most common cause, but it's one of the more common causes of people being thrown into decay or HHCNS. But what are some other considerations you need to keep at the back of your mind if you are triggering a patient with decay, HHCNS? You actually want to make sure that you look for something that may be triggering their underlying condition, right? So they may have an infection that may be triggering their, in fact, their decay or HHS. They may have an MI, right? So you want to check like, components, you want to check a white count or you want to check a CBC with differential, right? You just want to make sure you evaluate them for something bad that may be happening, that may be causing their, that may be triggering.

Because again, remember, if you're stressed, if your, if you're sick or if you have an MI, your body interprets that as metabolic stress. So your stress hormones get released like cortisol and if cortisol gets released, it will make you hyperglycemic and it can throw you into decay, okay? So you need to look for those underlying causes. And then another high-yield thing you want to keep at the back of your mind is if you correct the glucose too quickly, right? So you'll probably remember this mantra that relates to sodium, right, from step one, right? So like from low to high, the pons will die, from high to low, the brain will blow, right? So if you correct hyper, neat, trimia too quickly, right? Those patients can have cerebral edema and herni-den die, right? Don't want that. Same thing, right? In fact, sort of think of it with like hyper, neat, trimia, hyperglycemia. If you correct the person's glucose a little too fast, you can actually also get into trouble with cerebral edema, right? And classically, the way they'll present on an exam is if a patient becomes like more somnolent, they become like less arousable, they become disoriented, and they're getting an insulin infusion for the treatment of decay or HGSNS. You want to begin to think about cerebral edema, right?

And there are certain things you could have done in the first instance to sort of like decrease the risk of that happening, like adding the extrus when a decay person's blood glucose dips below 200 or adding the extrus when a HGSNS person's blood glucose is in that 250, basically dips below that 250 to 300 range, okay? So those are things to think about. And again, if the person like becomes combatoes, right? You mean you could consider a manateau? Manateau is probably the right answer on an exam or like 3% hypertonica ceiling. Okay, so I'm just trying to think if there is any other high-yield major thing I want to talk about personally. I think that's all I want to say with regards to DKA, HGSNS. Again, don't forget, just key things, just as a quick high-yield key don't forget, right? They come in, get your BMP, get your CBC, if they have ketosis, if they have ketones or an acidemia, they have DKA. If they don't have ketones or acidemia, they have HGSNS, right? Look at the potassium. If it's less than 3.3, you cannot start insulin. If it's between 3.3 and 5.3, go ahead and include insulin with the fluids they're getting. In terms of fluids, you can give initial boluses of like a liter an hour. Okay, you can give it up to like two, three liters of thereabouts and then after that you need to start them on like maintenance fluids, right?

And the way you make that determination is if you calculate the corrected sodium, adi is the acid is there adi hyper nitrimic, or is the sodium normal? If the hyper nitrimic on the sodium is normal, you go ahead and you can put them on a 0.45% ceiling. So half normal if you have a hyper nitrimic after you calculate the corrected sodium, then you start them on, you continue them on normal ceiling and you can do that at a rate of like 250 cc per hour or you can go a little higher if they're like really really volume down, right? And then don't forget key transition things, right? You want to make sure that if a person has DKA and they have blood glucose dips below 200 adi, so add the extrace to their fluids. If it's HGSNS person, if it dips below like the 250 to 300 range, just think of just remember 250. If it dips below 250 and you're in HGSNS, go ahead and add the extrace to their fluids. And again remember, if they have a potassium between 3.3 and 5.3, it's recommended that you add like 20 milli equivalents of potassium to every liter of fluid that they're getting. And other key things to keep in mind, right? So if a person's, if a person's in DKA and they have gap closes, or a person is in HGSNS and their glucose dips, and their glucose dips below 250 and the patient is demanding to eat. So again, these are the things that tell you that you can start subcue insulin. For a DKA person, did the gap close, right? So as the gap close, is their glucose less than 200?

For HGSNS person, is their glucose below 250 and adi, demanding food, okay? If you get to that point, then go ahead and start subcutaneous insulin. Postad that subcutaneous insulin while their insulin infusion is still running, okay? When they're, when they've gotten the subcutaneous insulin for like a 2-up period, they you can turn off the insulin infusion. And I said that if a person is insulin naive, or you don't know what their insulin regimen at home looks like or should look like, let's say it's like a non-compliant patient, you can consider studying them like insulin at like 0.5 units per kilogram, right? Multiply that by their body weight, right? And then basically, um, DV that into 2, the first half of that, um, is their basal insulin, what they get like at my during the morning or whatever they're long acting. And then the other number, you get the other half divided into 3 and give that amount to them with each of their 3 meals for the day, okay? So those are key things you want to keep in mind. Don't crash the glucose too quickly, right? So usually lower the glucose by like 50 to 70 milligrams per deciliter per hour. If it's not going down by that much, you may want to up your insulin infusion rate. If it's going down too quickly, you want to decrease your insulin infusion rate. So those are the high-yield things you want to keep at the back of your mind. And again, this topic is very commonly tested.

Don't forget the server-ladima that can happen if you correct a little too quickly. So with that, I'm going to close, um, but I just want to throw out there. I do offer one on one tutoring for the USM at step one, two CK, two CS step three exams, uh, the medicine-entrining exam, the medicine-board exam, uh, the preclinical med school exams, right? So like your first and second year exams, and then the third year partnership by shelf exams. And then if you have an acquaintance that needs to be done for like biochemistry, organic chemistry, general chemistry, physics, physiology, I do a histology even, I do a tutoring for all those. Um, and then if you're a med student applying to residency, so an ERAS application or a college student applying to med schools on AMCAS application, I do offer, um, consulting for those. So I do like interview prep. I have a personal statements with, um, preparing applications and whatnot. Um, because I have a lot of familiarity with that process and I've been on, uh, the admissions committee of like a top two med school in the country for like a year. And pretty much everyone advised me this last cycle matched. Um, so it's just one of those things I guess dig that forward you will. So I'll see you in the next podcast, have a wonderful day and God bless you. I'll see you next time.

DKA involves ketonuria/ketonemia and metabolic acidosis (low bicarbonate); HHS does not have these findings.

Polyuria, polydipsia, and general malaise ("feeling pretty crummy").

Lactated Ringer's solution (LR) or Normal Saline (NS).

Potassium supplementation (e.g., 20 mEq per liter).

A drop of 50–70 mg/dL per hour.

Dextrose (dextrose-containing fluids).

A minimum of two hours.

Diabetic Ketoacidosis (DKA).

Hyperosmolar Hyperglycemic State (HHS).

K+ < 3.3 mEq/L.

Half Normal Saline (0.45% NS).

DKA: Anion gap closes (<12) AND glucose < 200 mg/dL. HHS: Glucose < 250–300 mg/dL AND patient is demanding food.

Cerebral edema (or cerebral herniation).

Diabetic Ketoacidosis (DKA).

Hyperosmolar Hyperglycemic State (HHS).

K+ < 3.3 mEq/L.

Half Normal Saline (0.45% NS).

DKA: Anion gap closes (<12) AND glucose < 200 mg/dL. HHS: Glucose < 250–300 mg/dL AND patient is demanding food.

Cerebral edema (or cerebral herniation).