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Urine Ketones do not measure beta-hydroxybutyrate, Urine dipstick has sensitivity of 95% and predictive value negative of 98% for diagnosis of DKA and DK. ABD pain is very common as a result of the acidosis, but if it persists despite resolution of near normal pH, consider searching for an intra-abdominal cause of the initial decompensation into DKA. However, the glycolytic enzyme phosphofructokinase is inactivated by decreasing pH and, thus, the glucose utilizationin brain cells is impaired.  This can result in coma or death.
OnceDKA is resolved, if the patient is NPO, continue intravenousinsulin and fluid replacement and supplement with subcutaneousregular insulin as needed every 4 h. Since acetone is highly lipid soluble, it will continue to be released from tissues for ~48 hours and will cause a positive urine ketone test. Increase in the anion gap should equal the decrease in bicarb unless a mixed picture is present.
Urine ketone dip test as a screen for ketonemia in diabetic ketoacidosis and ketosis in the emergency department. The sensitivity of the UKDT for the detection of ketonemia in all patients with DKA or DK was 97% (95% CI, 94% to 99%). RESULTS: The study group comprised 697 patients, including 98 patients with diabetic ketoacidosis (DKA) and 88 with diabetic ketosis (DK). The occurrence of diabetic ketoacidosis in non-insulin-dependent diabetes and newly diagnosed diabetic adults. Nonspecific hyperamylasemia and hyperlipasemia in diabetic ketoacidosis: incidence and correlation with biochemical abnormalities. Type 2 Diabetes Presenting as DKA Adults not infrequently present to the ED with new-onset diabetes, which is almost always type 2 diabetes. With mildDKA, regular insulin given either subcutaneously or intramuscularlyevery hour is as effective as intravenous administration inlowering blood glucose and ketone bodies (27).
Related Articles, Links Effect of 50 milliliters of 50% dextrose in water administration on the blood sugar of euglycemic volunteers. Hi, If truly we can send insulin drip patients to regular floors, then I agree we should drip all of our DKAs. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising.
Clipping is a handy way to collect and organize the most important slides from a presentation. Lipohypertrophy is a medical term that refers to a lump under the skin caused by accumulation of extra fat at the site of many subcutaneous injections of insulin. Rotate your sites for injections and for insulin pump insertions by asking your medical team, clinic, diabetes educator or doctor to provide practical guidance, including a site chart to take home if necessary. The Aim CentreThe Aim Centre are the Hunter's Specialists in Prevention, Detection and Management of Diabetes. A fistula is an abnormal channel leading between two cavities or surfaces which may drain a fluid material such as saliva or pus. Branchial cleft cyst (lateral branchial arch cyst) – the most common developmental cyst of the side of the neck.
Preauricular pits and sinuses – these are common, affecting 1% of the population, particularly Asians and blacks.
Chronic osteomyelitis – most commonly associated with poorly controlled diabetes mellitus or following radiotherapy to the jaw for cancer or Paget disease of the bone. When talking about common foot deformities the type of deformity that comes to mind is the Claw Toe Deformity which is felt to be normally caused due to poor footwear where the shoe is quite narrow near the toe end thus cramping the toe for space resulting in Claw Toe Deformity, although the fact of the matter is that Claw Toe Deformity can also be caused due to some type of nerve damage in the toe area of the foot due to underlying medical conditions like diabetes mellitus. One common cause of Claw Toe Deformity is some sort of injury or trauma to the toe or ankle region of the foot such as those injuries sustained while playing contact sports like soccer and rugby.
Alcoholism As A Cause For Claw Toe: Excessive intake of alcohol causes significant nerve damage and makes the muscles of the toes weak causing Claw Toe Deformity.
Cerebral Palsy: This is a neurological condition which adversely affects the muscle tone of the body.
Charcot-Marie-Tooth Syndrome: It is a type of an inherited muscular disorder in which the muscles become extremely weak in the body, including the foot region which can cause Claw Toe Deformity.
Arthritis: This is also one of the common causes of Claw Toe Deformity as due to arthritis the ligaments of the foot become weak and start causing different foot deformities of which Claw Toe Deformity is one. Spine Problems: If an individual has any problem with the spinal cord then this may cause significant damage to the nerves of the foot leading to Claw Toe Deformity. Literature suggests that there is often a lot of confusion between what is a Claw Toe Deformity and what is Hammertoe Deformity as they both are quite similar with the main difference between them being the muscles affected in the two deformities which are different.
Claw Toe Deformity is a visible deformity and can be seen easily by noticing that the toe is not in its normal anatomical position. Once you observe that your toes are bent and you are not able to straighten it up then it is recommended that you see a physician for an evaluation as it may be a Claw Toe Deformity. In the initial phase, even with a Claw Toe Deformity you will be able to move the toe but as time passes by the toe starts to become hard and it becomes difficult to move the toes so it is important to get the deformity treated at its earliest stage.
Wear footwear that have ample amount of toe space so that the toes do not get cramped up and also avoid wearing high heeled shoes or sandals to keep the toes in natural position. Stretch the toes as much as possible if you are wearing tight fitting shoes at the end of the toe so that the joint does not become stiff and stays anatomically correct.
Try to pick up small pieces of articles like tiny bits of paper or stones using the toes so that they remain flexible.
There are special pads available in the market which tend to relieve some pressure off of the toe and keeps them flexible. In case these treatments are not helpful in correcting the deformity then the only other option left is a corrective surgery for Claw Toe Deformity.
The most common complication of Claw Toe Deformity is development of calluses or corns on the foot.

In the subgroup of patients with DKA, the sensitivity of the UK was 97% (95% CI, 92% to 99%). The sensitivity, specificity, positive, and nega tive predictive values of the urine ketone dip test for the detection of DKA were 99% (95% CI 97% to 100%), 69% (95% CI 66% to 73%), 35% (95% CI 29% to 41%), and 100% (95% CI 99% to 100%), respectively.
We excluded patients who had persistent hypotension (systolic blood pressure <80 mm Hg) after the administration of 1 liter of normal saline, comatose state (loss of consciousness), acute myocardial ischemia, heart failure, end-stage renal disease, anasarca, dementia, or pregnancy.
When these occurred, intravenous insulin infusion or subcutaneous lispro was discontinued 1 hour after the administration of patients? maintenance dose of regular and intermediate-acting insulin. It may be unsightly, mildly painful, and may change the timing or completeness of insulin action. Developing a plan for site injections will provide a more comfortable, and effective foundation for complication-free insulin therapy. An example would be from the mouth (oral cavity) to the skin surface, usually of the face or neck, and this specific type is called an orocutaneous fistula. An example would be a dental sinus draining from a dental abscess to either the inside of the mouth or the skin.
Any type of surgical procedure to the ankle may also cause muscle weakness resulting in Claw Toe Deformity.
When the muscle tone of the foot region gets adversely affected it may cause Claw Toe Deformity.
Another striking difference between the two deformities is that a Claw Toe Deformity affects more than one toe at a time whereas Hammertoe Deformity affects only one toe at a time.
Claw Toe Deformity gets its name from the way the toe is shaped as it is bent at the proximal interphalangeal joint and the distal interphalangeal joint. The treating physician will conduct certain tests to rule out any nerve damage due to medical conditions that may make the muscles and nerves of the foot weak. For correction of Claw Toe Deformity in its initial stages, the treating physician will recommend splints or tape so that the toe remains in normal position. The calluses are formed as the deformity puts the foot in a position where the other parts of the foot feel the pressure resulting in the formation of corns or calluses. If there is a neurological condition causing the deformity then it becomes extremely vital to get the condition treated to prevent further complications.
When the patient is able to eat, a multiple-doseschedule should be started that uses a combination of short-or rapid-acting and intermediate- or long-acting insulin asneeded to control plasma glucose. For DKA and DK, the sensitivity, specificity, positive, and negative predictive values of the urine ketone dip test were 95% (95% CI 90% to 97%), 80% (95% CI 76% to 83%), 63% (95% CI 57% to 69%) and 98% (95% CI 96% to 99%). Nineteen percent of the patients in whom diabetes was a new diagnosis and 52% of the patients who had a prior history of NIDDM were > or = 40 years old.
In 30 patients, the cause of abdominal pain was considered to be secondary to the precipitating cause of metabolic decompensation. Emergency Physicians must not reflexively attribute the acidosis to dehydration, lactic acidosis, or another cause and must recognize that patients with type 2 diabetes may present with DKA. By hospital policy, the IV insulin group was managed in the ICU while the alternate group was managed in a step-down unit or general medicine floor. I would say that, while it is acceptable in mild DKA to use hourly sq insulin with hourly iv boluses for high sugars, it is pretty burdensome for physicians, nurses and rather painful for the patients.
It is a common, minor, chronic complication of diabetes mellitus.  The skin will usually feel firmer than the skin elsewhere on your body. It may burst to form a sinus which usually opens just below the hyoid bone in the midline of the neck.
It usually opens on the side of the neck just above the junction of the collarbone and breast bone (sternoclavicular joint), in front of the sternocleidomastoid muscle. The sinus opening (pit) is usually located just in front of the upper part of the ear where the cartilage of the ear rim (helix) meets the facial skin.
Another thing about Claw Toe Deformity is that if this condition is not corrected in its initial phase then it may become a permanent deformity. Apart from that, Claw Toe Deformity is normally caused due to excessive alcohol intake and medical condition like diabetes mellitus.
The bend is so obvious that one can see the toe being bent under and the toe is extremely stiff. The physician will also inquire about you sustaining any injury to direct blow to the toe during any activity. In case of diabetes, it is again important to keep the blood sugars under control in order to prevent complications. Continue intravenous insulininfusion for 1?2 h after the split-mixed regimen is begunto ensure adequate plasma insulin levels. The anion gap and serum bicarbonate level were less sensitive but more specific than the urine ketone dip test for the detection of DKA and DK. Of patients with follow-up of at least 12 months, about 24% of the newly diagnosed and 8% of those with a history of NIDDM were not taking insulin.
These criteria were determined based on the data from the first 11 patients diagnosed with fulminant diabetes, as reported by Imagawa et al.
Type 2 diabetes is by far the most common type of diabetes, and is characterized by variable degrees of insulin deficiency and resistance; it occurs in people over age 40 who are likely to be obese. RESULTS: There were no significant differences between the groups in baseline characteristics, or in the rate of decline of the plasma glucose level, correction of acid-base parameters, duration of insulin treatment or hospital stay, or amount of insulin given until DKA was resolved.
They are asymptomatic unless infected (uncommon), when they become red, sore and may discharge pus. Shoes that do not fit properly are also one of the causes of Claw Toe Deformity where the toe gets cramped for space and moves upwards. Because of this stiffness and inability to move the joint, this deformity causes a lot of pain in the toes, although in some cases it is absolutely painless.

In case of this deformity is caused due to ill fitting footwear then make sure that you get the right shoe for your size with extra space for the toes so that they do not get cramped up and hence put pressure on the remaining part of the toes resulting in Claw Toe Deformity. An abrupt discontinuationof intravenous insulin coupled with a delayed onset of a subcutaneousinsulin regimen may lead to worsened control; therefore, someoverlap should occur in intravenous insulin therapy and initiationof the subcutaneous insulin regimen. Multiple regression analyses showed significant correlation of pH and serum osmolality with amylase elevation. The mean age at onset of type 1 diabetes was 39.1 years in fulminant type 1 diabetic patients and was significantly older than age at onset in autoimmune type 1 diabetic patients. However, it is occasionally difficult to distinguish between type 1 and atypical presentations of type 2 diabetes.
To explain this in medical terminology, due to ill fitting shoes the muscles in the toe region become significantly tight as there is no space for the toe to be in a relaxed position for prolonged periods of time which results in contraction of the tendons of the toes and hence the toe is unable to become straight even after coming out of the ill fitting footwear.
There may also be development of corns or calluses due to the friction created between the knuckles rubbing against the footwear. DKA can occur in the presence of partial (but not complete) insulin deficiency, and therefore cannot be relied upon as an absolute indicator that the patient has type 1 diabetes.
The mean charges for DKA treatment were significantly reduced in the insulin lispro group ($8,801 vs.
METHODS: This was a prospective, interventional study conducted from the ED of an urban, university-affiliated hospital. Typically, the stress of infection causes increased secretion of counterregulatory hormones and an increase in insulin resistance.
Amylase elevation is correlated with pH and serum osmolality, but lipase elevation is correlated with serum osmolality alone.
One patient with HHS reported nausea and vomiting on admission, but abdominal pain was not reported in any patient with HHS. A proposal of three distinct subtypes of type 1 diabetes mellitus based on clinical and pathological evidence. The already impaired insulin secretion is unable to respond to the increased demand, leading to hyperglycemia. CONCLUSIONS: In stable adults with uncomplicated DKA, administration of subcutaneous insulin lispro was as safe and effective as infusion of regular insulin, but did not require ICU admission and was associated with a significant reduction in the costs of care.
High behavior blood pressure ¦ Assist the patient in ¦ These risk¦ Inaccurate does not mean identifying factors have follow through excessive modifiable risk been shown to of instructions. Diagnosis of AP based solely on elevated amylase or lipase, even > 3 times normal, is not justifiable.
CONCLUSIONS: Gastrointestinal manifestations including abdominal pain are common in patients with DKA and are associated with severe metabolic acidosis and with a history of alcohol or cocaine abuse, but not with the severity of hyperglycemia or dehydration. Our study indicates that investigation of the etiology of abdominal pain in DKA should be reserved for patients without severe metabolic acidosis or if the pain persists after the resolution of ketoacidosis. These patients typically are African-Americans, or are of African, Hispanic or Caribbean descent.
The main outcome measures were post-D50W serum glucose levels (observed) at 5 predetermined time intervals (5 min, 15 min, 30 min, 1 hr, and 2 hr). Would you like to have an interdepartmental conference, or do you want to hold off until we identify a problemmatic case? KPD has been reported to account for up to 60% of cases of new onset-diabetes with DKA in US African-American and Hispanic patients (3). An expected change in serum glucose was calculated using the volume of distribution formula for glucose.
Titration with sc hourly dosing is easy, just adjust the amount given sc, insulin drips are not titrated more frequently than q 1 hour.
Ketosis-prone diabetes – a new subgroup of patients with atypical type 1 and type 2 diabetes? CONCLUSION: Without pre-intervention blood drawing by emergency medical services, it is not possible to accurately predict pre-D50W serum glucose levels based on post-D50W glucose levels. The diagnosis of hypoglycemia as the etiology of altered mental status must therefore remain a diagnosis of exclusion. In addition, the return of serum glucose to baseline after 30 minutes suggests the duration of the effect of 1 ampule of D50W.
Frequent re-evaluation of the serum glucose levels of suspected or proven hypoglycemic patients after administration of D50W should be considered. I use this strategy only at Sinai, at Elmhurst, the increased availability of CCA beds makes these extra sticks to the patient unnecessary. At Sinai, with only 4 stepdown beds, it does not seem to make sense to start an insulin drip in mild cases of DKA. If you have any cases where patients are being managed solely with IV insulin boluses, I would appreciate it if you brought them to our attention so that we may refer the cases for QA.
In short, from my perspective, trending the anion gap is quite useful to guide continuing therapy, but the presence of a gap alone is not an indication for an insulin drip, though certainly an indication for hourly insulin and a trending of the gap for resolution.
As to sugar levels,  DKA is absolutely possible at sugar levels <200, but I think it behooves  the treating physician to consider other causes of anion gap acidosis in these patients before falling back on DKA as a diagnosis. It would be great to get together and discuss these issues further as it seems an area ripe for the creation of interdepartmental guidelines for the better care of these patients.

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