Both diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are usually triggered by a precipitating cause: infection, infarction, infant on board (pregnancy), dietary indiscretion, and insulin deficiency. (The “five Is.”)
In DKA, the pH is typically < 7.3, anion gap > 10, serum bicarbonate < 18 mEq/L, and with both elevated urine and serum ketones.
In HHS there is typically no ketosis and a normal anion gap, but serum osmolality > 320 mOsm/kg.
In most adult cases of DKA, fluid deficit is estimated to be 3 to 6 L; in HHS, the deficit is 9 to 12 L.
Provide volume resuscitation before starting insulin therapy, as it will decrease hyperglycemia 35 to 70 mg/dL, even without insulin.
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME credits
Upon completion of this article, you should be able to:
Identify common precipitants of diabetic ketoacidosis and hyperosmolar hyperglycemic state
Identify metabolic derangements indicative of hyperglycemic emergencies and determine strategies for correction
Select appropriate crystalloid and insulin rates for resuscitation and ongoing treatment
Discuss indications for supplemental therapies, such as sodium bicarbonate and phosphate.
Date of Original Release: February 1, 2020. Date of most recent review: January 10, 2020. Termination date: February 1, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2019. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.
AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours per issue by the American Osteopathic Association.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Pharmacology CME credits.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Dingle, Dr. Slovis, Dr. Parsons, Dr. Pfennig-Bass, Dr. Mishler, Dr. Toscano, Dr. Jagoda, and their related parties report no relevant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of the article. (2) Mail or fax the CME Answer And Evaluation Form (included with your June and December issues) to EB Medicine.
Hardware/Software Requirements: You will need a Macintosh or PC to access the online archived articles and CME testing.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit www.ebmedicine.net/policies.