Potpourri: Euglycemic DKA, Slit Lamp, Abd Pain in Pregnancy
Nice shift. Some pearls and some self-learning.
1. Euglycemic DKA
Source: Plewa MC, Bryant M, King-Thiele R. Euglycemic Diabetic Ketoacidosis. [Updated 2023 Jan 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. [pubmed]
Don't forget that DKA can occur in individuals without an elevated blood glucose! Failing to recognize eu-DKA can lead to delayed diagnosis and treatment, with potential adverse consequences.
The new 2024 ADA definition of DKA accounts for this possibility. DKA is now defined by D (Dextrose - Glucose > 200 or HISTORY of DKA), K (Ketones in the urine or serum), A (Acidosis—either by pH or CO2)
Pathogenesis: Primarily due to decreased hepatic production of glucose during a period of absolute or relative insulin deficiency compared to glucagon. Essentially, there is a decreased insulin:glucagon ratio, promoting ketoacidosis, in a person with poor glucose reserves.
Common causes: Alcohol use, pancreatitis, chronic liver disease, pregnancy, and SGLT2s
Patients may also have deceivingly low glucose levels due to home insulin administration before arrival to the ED.
Barski, 2019
2. Slit Lamp Exam
See this EyeWiki page for a review on some of knobology and approach.
See this video on Cell-and Flare, which is a common finding in particularly anterior uveitis or iritis.
Good review for me as well. My slit lamp in residency was almost always broken—so I am also working on this!
3. Approach to Pregnancy and Abd Pain/Vaginal Bleeding
See the above flow diagram from my training hospital's ED Handbook.
Big believer in attempting our own bedside US to identify an IUP. Saves a huge amount of time.
If a patient presents in the first trimester with pregnancy and vaginal bleeding or abdominal pain, our job is to 1) consider GI pathology and 2) more importantly, rule out ectopic.
Unless the patient has significant vital sign abnormalities, significant symptomatic anemia or physical exam evidence that is concerning for anemia that would require a transfusion, or is undergoing hormonal treatment/IVF, there is no reason to get labs for every patient—especially that now ACOG has finally caught up on the no Rhogam <12 weeks thing.
Bottom Line: Patient comes in and finds out they're pregnant or has yet to get an US and has abd pain/vag bleeding--> Do a bedside US. If you see an IUP, congrats you're done. Discharge them with OB followup. Save them and the hospital 3-4 hrs of additional ED course time.
Best,
Dillon
