Makindo Medical Notes

🚑 DKA = medical emergency. Treat the triad (hyperglycaemia, ketonaemia, acidosis) and actively hunt the trigger. Don’t miss 🦠 sepsis, ❤️ MI, 🫀 pancreatitis, or 🤰 pregnancy—these kill patients if untreated.

🧑‍⚕️ OSCE Checklist — DKA with Triggers Integrated

1) ABCDE First

• Airway safe? Breathing: O₂ only if SpO₂ <94%.
• Circulation: 2× large-bore IV, continuous ECG, BP, SpO₂, strict urine output (catheter if needed).
• Disability: GCS, capillary glucose + ketones.
• Exposure: look for infection sources (chest, urine, skin/lines, wounds).

2) Confirm DKA (the Triad)

• 💉 Glucose > 11 mmol/L (or known diabetes)
• ⚡ Blood ketones > 3.0 mmol/L (or urine ≥ 2+)
• 🧪 Acidosis: VBG pH < 7.3 or HCO₃ < 15 mmol/L

3) Immediate Tests (Bedside + Labs)

• Bedside: CBG, capillary ketones, VBG (pH/HCO₃/K⁺/lactate), ECG.
• Bloods: FBC, U&E, LFTs, CRP, cultures (if sepsis suspected), troponin (now ± repeat), lipase (± amylase), β-hCG in women with childbearing potential.
• CXR if respiratory symptoms/signs; urine dip ± culture.

4) Fluids (adult template, individualise)

• If SBP < 90 mmHg: 500 mL 0.9% saline over 10–15 min; repeat until SBP > 90.
• Then ~6 L 0.9% saline over 18 h for a 70 kg adult (1 L/1 h → 1 L/2 h ×2 → 1 L/4 h ×2 → 1 L/6 h), adding K⁺ as below.
• Use caution/closer monitoring in young, elderly, pregnancy, renal/cardiac disease.

5) Potassium (replace early, monitor hourly initially)

6) Insulin & Glucose

• Start FRIII: 0.1 units/kg/h IV (e.g., 50 units Actrapid in 50 mL 0.9% saline). No IV bolus.
• Continue basal (long-acting) insulin (e.g., glargine/detemir) at usual dose.
• When CBG < 14 mmol/L: commence 10% glucose at 125 mL/h alongside saline to allow ongoing ketone clearance with insulin.

7) Sepsis — Don’t Miss It (do within 1 hour if suspected)

8) MI — Screen Early

• 12-lead ECG on arrival ± repeat at 2–3 h if ongoing concern.
• High-sensitivity troponin now and per local ACS pathway.
• If ACS likely: involve cardiology; balance fluids carefully if cardiac compromise.

9) Other Triggers to Act On

• 🫀 Pancreatitis: lipase (preferred) ± amylase, triglycerides; abdominal US if biliary suspicion.
• 🤰 Pregnancy: urgent obstetric input; tighter fluid balance; fetal monitoring if viable gestation.
• Missed insulin/psychosocial factors: diabetes CNS review before discharge.

10) Monitoring & Targets

• Hourly CBG and ketones; VBG 2–4 hourly; strict fluids in/out; obs (HR, BP, RR, SpO₂, GCS).
• Targets: ketones ↓ ≥ 0.5 mmol/L/h; glucose ↓ ≥ 3 mmol/L/h; K⁺ 4–5.5 mmol/L.
• Resolution: ketones < 0.3 mmol/L, pH > 7.3, HCO₃ > 15, patient eating/drinking.

11) Step-down & Transition to SC Insulin

• When resolving and able to eat: give rapid-acting SC insulin with first meal, then stop IV insulin 30 min after.
• Continue/titrate basal insulin; provide sick-day rules and hypoglycaemia education before discharge.

12) Escalation (HDU/ICU criteria)

• pH < 7.0 or HCO₃ < 5; ketones > 6; K⁺ < 3.5 despite replacement; SaO₂ < 92% on air; SBP < 90; GCS < 12; severe comorbidity (elderly, pregnancy, renal/cardiac).

Common Pitfalls (say these in the OSCE)

• ❌ Stopping long-acting insulin.
• ❌ Failing to replace potassium adequately.
• ❌ Not starting antibiotics within 1 hour when sepsis suspected.
• ❌ Forgetting ECG/troponin (silent MI) or lipase (pancreatitis).
• ❌ Fluid over-resuscitation in frail/cardiac/renal patients.