practice updates

Questions Addressed:

• When you are suspicious for DKA do you obtain a VBG or an ABG? How good is a VBG for determining acid/base status?
• Do you use serum or urine ketones to guide your diagnosis and treatment of DKA?
• Do you use IV bicarbonate administration for the treatment of severe acidosis in DKA? If so, when?
• When do you start an insulin infusion in patients with hypokalemia? Do you give a bolus followed by a drip?

Thus far we have discussed resuscitation in trauma and sepsis.  What distinguishes those two from the resuscitation goals in DKA is timing.  In trauma and sepsis, it’s all about early recognition, aggressive and quick optimization, and understanding all the possible treatment options at your disposal.  In the management of DKA, it’s quite the opposite.  If you remember anything from this discussion, it’s that slow and steady wins the race!  In fact, overaggressive resuscitation is what leads to the most significant morbidity and mortality in DKA patients.  Patients in DKA don’t die from the disease process – they die because we kill them! […]

In November 2001, Dr. Manny Rivers and his colleagues published an article in the New England Journal of Medicine on Early Goal Directed Therapy in Sepsis.  At the time, sepsis was not a new concept, nor was the treatment of it.  Where I believe the real genius in EGDT lies is in a fanatical focus on early recognition of sepsis by utilizing SIRS criteria, as well as developing an algorithm with definable objective treatment goals to assist providers in understanding if their treatment selections are in fact working.  The basic questions in EGDT therapy are:

1. How much fluid is enough?
2. Are the vital organs being perfused appropriately?
3. Is there adequate oxygen delivery and utilization by those vital organs?

Since Rivers published his article in 2001, it has been met with both acclaim and controversy.  EGDT utilizes central venous pressure monitoring, lactate trending, SvO2 monitoring, vasopressor therapy, and sometimes, blood transfusions to optimize resuscitation of the septic patient.  I believe the controversy is not in whether or not it works, as multiple studies have demonstrated a reduction in morbidity and mortality.  Instead, the controversy lies in what is the best modality to answer the basic questions of sepsis resuscitation, and whether some of the aggressive steps recommended in the initial study are necessary or even practical in many emergency departments across the country. […]

One of my colleagues likes to tell our residents, “they don’t come to the ED to die, they come here to live.”  It is our skill in identifying critically ill patients and successfully resuscitating them that defines us as emergency medicine physicians.  Resuscitation in its simplest term means to revive from unconsciousness or apparent death.  However, there are a multitude of different disease processes that cause critical illness, and the approach to resuscitation of each illness is quite different.  It is important to have a confident grasp of different resuscitation options and endpoints so you can best help your patients.  If you try to resuscitate all of your patients in exactly the same manner, you will actually end up harming many of them instead.

The goal here is to understand the resuscitation technique and endpoints in trauma, sepsis, and diabetic ketoacidosis.  The tried and true methods will be summarized, and areas where controversies exist will be discussed as well.  As a result, there is a wealth of information that we need to get through.  In order to lay it out for you in smaller, digestible bites, I am going to roll this out in installments.  First up….trauma! […]