Description:

Experts: Dr. Bernard Mwesigye & Dr. Umarashid Guloba

In this episode

A young type 1 diabetic patient arrives with: Restlessness, agitation, confusion (GCS 9/15)·

Vital signs: HR 146, RR 30, SpO₂ 89%, BP 186/89·

Key finding: Vitiligo patches on skin — signaling autoimmune disease (type 1 diabetes)·

History: Several days of vomiting/diarrhoea → couldn't keep food or insulin down

· Labs: Glucose 19 mmol/L, HbA1c 14%, ketonuria 3+· Diagnosis: DKA precipitated by gastroenteritis.

KEY DISCUSSION POINTS

1. Diagnosis & Differentials

· DKA confirmed (hyperglycaemia + ketones + acidosis)

· HHS ruled out (significant ketones present)

· Hypertension = symptom of metabolic crisis, not primary problem

· Sepsis considered — gastroenteritis = trigger; antibiotics started

2. The "Golden Rule" of DKA Management

NEVER give insulin if potassium < 3.5 mmol/L

· Insulin drives potassium into cells → can cause fatal arrhythmias

· Sequence: Check K⁺ → Replace if low → THEN start insulin

3. Four Treatment Pillars

Fluids 5–6L deficit; switch to dextrose when glucose < 14

Glucose Insulin 0.1 U/kg loading + infusion; reduce gradually

Electrolytes Potassium first; monitor every 2–4 hours

Acidosis Insulin stops ketones; bicarbonate almost never

4. Critical Pitfalls to Avoid

· Giving insulin before checking potassium

· Dropping glucose too fast → cerebral oedema

· Not treating the underlying trigger (infection)

· Stopping monitoring too early — patients can deteriorate rapidly

5. Euglycaemic DKA (Emerging Danger)

· Seen with SGLT-2 inhibitors (empagliflozin, etc.)

· Glucose may be normal despite full DKA

· Always check ketones in sick patients on these drugs

6. Uganda Context

· Insulin access, cost, and cold chain are major challenges

· Diagnosis possible with minimal resources: glucometer + urine dipstick + clinical exam

· Family education on warning signs and adherence is essential to prevent recurrence

Five Takeaways

1. Examine the whole patient — vitiligo signaled autoimmune type 1 diabetes

2. Four goals: Fluids → Glucose → Potassium → Acidosis

3. Potassium rule: Replace if < 3.5 BEFORE insulin

4. Find and treat the trigger — infections are the commonest cause5. Educate family — prevents the next admission

Listen to learn. Share to save lives. Mastering Emergency Care

Disclaimer: For Educational Purposes only, refer to guidelines for definitive management

Show Notes & Resources: