Texas EMS Magazine, Volume 18, Number 2, March/April 1997 Page: 43
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G'dutinuing
SdHAwiCHens the cardiac action potential. This
occurs because an elevated serum po-
tassium level causes an earlier open-
ing of the potassium channels in the
membrane. These channels control
the outward (repolarizing) current.
This results in an accelerated repolar-
ization and a partial depolarization
during diastole.
The initial indications of hyper-
kalemia are the appearance of tall,
thin T-waves and shortened Q-T in-
tervals. These are indicative of the
accelerated repolarization. As the hy-
perkalemia progresses, irregularity
develops, the PR-interval lengthens,
the QRS complex widens and the ST
segment becomes depressed. This in-
dicates delayed conduction attributed
to the partial depolarization in the ad-
vanced stages of hyperkalemia. The
P-waves widen to the point of disap-
pearance, and the QRS complex con-
tinue to widen until ventricular
extrasystole develops, and finally V-
fib results.
Management
A patient suffering from DKA is
in jeopardy, not from hyperglycemia,
but from the resultant hypoperfusion
and metabolic acidosis. The interven-
tions chosen should be aimed at cor-
recting the acidosis and replenishing
fluids.
The first step is, as always, estab-
lishing and maintaining a patent air-
way. This is especially important in
the comatose patient who may have
vomited. After determination that
the patient is indeed experiencing
DKA, appropriate treatments should
be initiated.
The initial treatment, after airway
security has been addressed, includes
establishing two large bore IVs of
normal saline, with maxidrip admin-istration sets.
The management of the hypov-
olemia is of particular importance to
the prehospital provider, as it is most
often the only prehospital treatment
the patient with DKA can receive.
Hypoperfusion is a common
cause of death in the untreated DKA
patient. This is because the severe
volume depletion experienced by
these patients results in hypovolemia,
acute tubular necrosis and uremia.
Therefore it is easy to see why fluid
replacement is a critical intervention.
A person whose DKA has progressed
to the point of diabetic coma can lose
approximately 10 percent of their
body weight as well as approximately
40 grams of sodium. For these rea-
sons, the fluid of choice is 0.9 percent
sodium chloride, 2-3 liters initially,
run wide open. If the patient's car-
diovascular function has been com-
promised, a slower infusion rate is
indicated. Caution should be exer-
cised when continuing an infusion of
normal saline when the initial 2-3 li-
ters has been administered, as hyper-
chloremia acidosis may result from
the overuse of chloride-based solu-
tions. This acidosis is avoidable
through appropriate management of
fluid resuscitation. If allowed to de-
velop, hyperchloremia delays the cor-
rection of acidosis. To avoid this
complication, the use of either D5 W112
N5 or D10W11N5 should be considered
once serum glucose levels reach 200-
300 mg/dl. This also helps prevent
hypoglycemia which may result from
insulinization. Also, the infusion rate
may be reduced to run at 100-125 ml/h.
Constant reassessment to evaluate the
effectiveness of fluid resuscitation
should be performed. This reassess-
ment can consist of orthostatic vital
signs, improved skin turgor, in-Texas EMS Magazine March/April 1997
43
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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/m1/43/: accessed July 18, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.