A case of DKA & chest pain

[poppy07]

I thought this was a fairly interesting patient... young lady comes in with DKA and chest pain. Her glucose in the 300's, put on NS and received nitro paste % continuous rate insulin drip, while in E.D., arrived to unit: then bolus of 1 liter 1/2 NS with Bicarb, then 1/2 NS, then D51/2 NS. She eventually complained of a headache...medicated with Tylenol...her neuro status was quite consistent, AA&0x4. after medicating, pt rests (came in very early a.m.---maybe genuinely tired), or was a slight change in her mental status? was the headache from the nitro paste or from some mild cerebral edema, perhaps?

What do you think?

[ukstudent]

Why do you think there was any cerebral edema?

[poppy07]

it's possible with the rapid fluid shifts that cerebral edema can occur.

[EricJRN, MSN, RN]

How old was the patient? Cerebral edema is primarily seen in pediatric patients. Any lab results that stand out other than the glucose? What was the timing of the headache in relation to the Nitropaste? Was CT or MRI performed?

[RN1980]

i agree, tend to think maybe headache is from nitro and over all feeling bad. if this was a really bad dka episode for her with her ph all out of wack that will make you feel like crap. but sometimes it's very hard to pick up subtle neuro changes in pt's.

[Spatialized]

Headache is more than likely from the nitro. Seen it many, many times. May have also been a synergistic effect with the vasodilation from the nitro and fluid shift. Since you said she was mentating just fine, my gut still says nitro.

Tom

[FireStarterRN, BSN, RN]

I would lean towards the nitro paste, in addition to the fact that a headache could just be from feeling crappy. Was sugars in the 300s her admit sugars to the ER? That actually doesn't sound so bad, sugar wise, compared to some DKAs I've had.

[meandragonbrett]

I would say it's the NTG.

[cardiacRN2006, ADN, RN]

Yep, I'd say it's the nitro as well...

[pinksugar]

Was sugars in the 300s her admit sugars to the ER? That actually doesn't sound so bad, sugar wise, compared to some DKAs I've had.

I know! We don't even get DKA pts unless their sugars are in the 500-600's in my ICU. They will go to a medical floor or be treated in the ER.

Poppy, my guess is that the HA was cause by the nitro paste. I have seen that several times. In fact, one time I gave myself a HA from nitro because I hadn't noticed that there was a small hole in my glove and I got the paste on my finger!:angryfire

[Dinith88]

I thought this was a fairly interesting patient... young lady comes in with DKA and chest pain. Her glucose in the 300's, put on NS and received nitro paste % continuous rate insulin drip, while in E.D., arrived to unit: then bolus of 1 liter 1/2 NS with Bicarb, then 1/2 NS, then D51/2 NS. She eventually complained of a headache...medicated with Tylenol...her neuro status was quite consistent, AA&0x4. after medicating, pt rests (came in very early a.m.---maybe genuinely tired), or was a slight change in her mental status? was the headache from the nitro paste or from some mild cerebral edema, perhaps?

What do you think?

Poppy, the H/A was probably from nitro (like everybody else said)...BUT, your thinking wasn't way off.

When someone comes in with true DKA (like your patient) their blood is very concentrated (from the hyperglycemia, polyuria, etc.) . If you TOO RAPIDLY drop the sugar from iv-insulin bolus the blood can TOO RAPIDLY lose its osmotic gradient (it can become rapidly hypotonic) . When this happens too quickly, the fluid from the (now relatively hypotonic and dilute) blood can rush into tissues... Including brain tissue....which is where cerebral edema can occur. This phenomena(sp?) is exactly why endocrinologists (or any doctor treating it) will bring down hyperglycemia in DKA over several hours rather than over several minutes. At least this is the theory...

The rapid fluid bolus you witnessed will unlikely cause cerebral edema in these patients and is kinda par-for-the-course in DKA.