Texas EMS Magazine, Volume 18, Number 2, March/April 1997 Page: 41
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also goes unchecked. As the capacity
to oxidize the ketones is surpassed,
the excess ketones are secreted in the
urine (ketonuria). The number of ke-
tone bodies eventually increases be-
yond the kidneys' capacity, and
subsequently accumulates in the
blood (ketosis). Because two of the
three ketone bodies (B-hydroxy bu-
tyrate and acetoacetate) are acids, this
accumulation of ketones in the blood
produces metabolic derangement
known as ketoacidosis. This acidosis
causes nausea and vomiting, which
further decreases the circulating
blood volume.
To combat the ketosis, the body
employs three lines of defense. First,
the buffer system is activated. As ac-
etoacetate is synthesized, hydrogen
ions are produced. These react with
bicarbonate to form carbonic acid,
and this in turn is converted to car-
bon dioxide and water. The lungs
then expel the carbon dioxide and
water while the kidneys excrete the
acetoacetate. The phosphate buffer
system works to buffer other ketone
bodies.
The second system activated is
the respiratory system. As the lungs
work to rid the body of excess CO2
and acetone, an odor of."rotten fruit"
or "nail polish remover" may be no-
ticed on the breath. This is the smell
of acetone. Also an increased rate
and depth of respirations may be re-
alized (Kussmaul's respirations).
Finally, the renal system attempts
to control ketoacidosis by increased
excretions. The decreased pH also ac-
tivates the ammonia mechanism,
which works to remove excess hydro-
gen ions.
When ketoacidosis is uncon-
trolled, the body's compensatory
mechanisms are overwhelmed, andketoacidosis worsens and serum pH
falls. When the acid overload is great
enough, diabetic coma ensues.
The body also metabolizes protein
to create cellular fuel. Protein metab-
olizes into amino acids, which are
broken down by the liver into glucose
and nitrogen. The increased gluco-
neogenesis further worsens the hy-
perglycemic state while increasing the
osmotic diuresis. This protein break-
down also causes a loss of intracellu-
lar potassium.
In addition to ketoacidosis, some
degree of lactic acidosis may also be
present. As polyuria, vomiting and
Kussmaul's respirations continue, the
plasma component of blood becomes
depleted, causing hemoconcentra-
tion. This restricts blood circulation,
and results in widespread, severe tis-
sue anoxia. Tissue anoxia results in
anaerobic metabolism and the pro-
duction of lactic acid, further decreas-
ing the serum pH. Hydrogen ions,
which have built up in the extracellu-
lar fluid, move to the intracellular
fluid. This causes intracellular potas-
sium depletion as potassium is forced
out of the cells by the hydrogen ion.
The patient also loses sodium,
phosphate, magnesium, chloride and
bicarbonate through excessive urina-
tion and vomiting.
The hyperosmolarity, which re-
sults from the hyperglycemia and ke-
tosis, causes water to move out of the
cells. The resultant intracellular de-
hydration within the central nervous
system manifests as some degree of
altered sensorium.
Decreased circulating volume,
metabolic acidosis and altered senso-
rium combine to create a dangerous
position for this patient. The de-
creased circulating volume causes hy-
potension and tachycardia as well asCoutiniuing
education1Texas EMS Magazine March/April 1997
412
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Texas. Department of State Health Services. Texas EMS Magazine, Volume 18, Number 2, March/April 1997, periodical, March 1997; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth1507927/m1/41/: accessed July 18, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.