A patient presents to the ED for management of a spider bite. Which of the following statements is correct regarding a bite from the spider pictured?
Intracranial hemorrhage (ICH) is associated with significant disability and mortality. Although evidence-based guidelines exist, many hospitals have their own institutional practice patterns, which can make it difficult to care for these patients in the ED. Dr. Debbie Yi Madhok, an emergency physician and neurointensivist, sat down with Dr. Derek Monette, the ALiEM Deputy Editor in Chief, to discuss updates in the management of ICH. This interview follows up her original popular 2017 ALiEM post on dilemmas in ICH management, and takes a deeper dive into the nuances of seizure prophylaxis, blood pressure control, and platelet transfusions. We present the podcast and key learning points.
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The Toxicologist Mindset series features real-life cases from the San Francisco Division of the California Poison Control System.
Case: A previously healthy 49-year-old woman presented to the emergency department (ED) with acute onset of confusion. Family members noticed her to have unsteady gait and she complained of blurry vision and difficulty urinating. She denied the use of any drugs or alcohol and took no medications. In the ED, her vital signs were: T 98.7, BP 95/59, P 130, RR 16, and O2 sat 100% on room air. Her pupils were 7 mm and reactive and her skin was dry. Bowel sounds were present. She had no focal neurological findings, but appeared “very confused” and “frightened.”
Serum electrolytes, CBC, and liver function tests were all unremarkable. She had a negative urine drug screen and alcohol level. The ECG demonstrated sinus tachycardia with normal intervals, and the brain CT was normal.
What are your next thought processes?
A middle-aged man with a history of diabetes and hypertension presents with nausea, vomiting, and shortness of breath. His laboratory testing is remarkable for a leukocytosis, ketonemia, and an anion gap acidosis (pH of 7.13). The EM resident caring for this patient is surprised to find that the blood glucose is 121 mg/dL.
Which home medication is likely responsible for this presentation?
The patient’s presentation is consistent with diabetic ketoacidosis (DKA) in the absence of hyperglycemia. This entity is known at euglycemic DKA and it is increasingly recognized for an association with a newer oral diabetic medication class, SGLT2 inhibitors. Examples include:
The FDA has approved these three SGLT2 inhibitors for Type 2 diabetics, and at times, they are prescribed off-label for Type 1. The mechanism involves decreasing glucose reabsorption in the nephron’s proximal tubule (via inhibition of the sodium-glucose linked cotransporter-2 protein). This results in increased urinary excretion of glucose that is independent of the body’s insulin secretion.1
Other potential benefits of this class of medications include:1–3
In 2015 the FDA issued a warning, however, that SGLT2 inhibitors may cause ketoacidosis, urinary tract infections, and urosepsis.4 Since then, multiple case reports have been published showing an association between SGLT2 inhibitors and the development of euglycemic DKA.
Euglycemic DKA is an uncommon and likely under-diagnosed phenomenon, best defined as DKA with a lower than expected blood glucose (less than 250 mg/dL according to the American Diabetes Association).4–6
Potential precipitants, in addition to SGLT2 inhibitors, include:7
EPs may delay diagnosis, given the modest glucose levels at the time of presentation. This, however, is false reassurance because DKA is not defined by an absolute blood glucose. Interestingly, patients with euglycemic DKA may have a normal mental status despite marked ketoacidosis, and vomiting seems to be a common complaint.5
Euglycemic DKA treatment is the same as traditional DKA, and includes hydration, insulin, and supportive care. Patients with euglycemic DKA may also need a dextrose infusion given the lower glucose levels.
The mechanisms by which SGLT2 inhibitors cause or predispose to euglycemic DKA are unclear and likely complex. SGLT2 inhibitors may lead to a decrease in either endogenous or exogenous insulin, and an increase in glucagon production.8 This insulin deficiency or resistance may be mild in Type 2 diabetics, however, preventing the profound spike in blood glucose seen in traditional DKA.7
The evidence suggesting a link between SGLT2 inhibitors and euglycemic DKA remains limited to case reports. Both the FDA and the European Medicine Agency have reported cases of DKA with unusually low glucose levels.4,9 Peters et al. reported 13 episodes euglycemic DKA in patients taking SGLT2 inhibitors, though most were Type 1 diabetics.10 In Japan, 28 cases of DKA or ketoacidosis in patients taking SGLT2 inhibitors have been reported as of 2015. Of these, the initial blood glucose is known in only 14 cases, but in 9 cases, it was <300 mg/dL.8
Our fifth case of season 5, The Case of the Night Shift Stimulants, presented the scenario of a junior emergency medicine (EM) resident who witnesses her attending physician taking stimulants in order to function during his night shift.
The MEdIC team (Drs. Tamara McColl, Teresa Chan, Sarah Luckett-Gatopoulos, Eve Purdy, John Eicken, Alkarim Velji, and Brent Thoma), hosted an online discussion around the case over the last 2 weeks with insights from the ALiEM community. We are proud to present to you the curated commentary and our expert opinions. Thank-you to all participants for contributing to the very rich discussions surrounding this case!
In this SplintER Series, we review splinting fundamentals, introduce advanced concepts, and highlight ways to implement these into your next shift. In SplintER 102, we reviewed the materials used in splinting and a general approach to applying a splint. Today’s post puts the spotlight on some of the potential complications of splinting, discharge care plans, and pharmacological adjuncts to aid in recovery.
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Computed tomography (CT) is increasingly available across U.S. Emergency Departments and has changed the practice of medicine. However, it is coupled with potential side-effects from radiation and contrast media. Emergency Medicine is beginning to make a concerted effort to identify clinical scenarios in which CT may be unnecessary, producing outcomes research and validated clinical decision rules. Renal colic and pulmonary embolism, in particular, seem amenable to this area of investigation. The ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements, reviewed this topic with experts Dr. Chris Moore (Emory University) and Dr. Jeffrey Kline (Indiana University). We present highlights from their discussion with Dr. Jason Woods.