Diabeticketoacidosis(DKA)emergencydepartmentofshengjinghospitalzhanghonglei第一页，共三十一页。case•Mrwang，M，52yearsold•chiefcomplaint：polydipsia,polyuria,weaknessfor1week，vomitingfor10hour•physicalexam:tachypnea,BP150/90mmHg,HR:120bpm,SaO2:99%•ABG:PH:7.06,PaCO2:12mmHg,PaO2:117mmmHg,HCO3-:3.4mmol/L,Lactate:3.1mmol/L,BE:-24.7mmol/L，AG:34.6mmol/L•BUN:15.9mmol/L,Cr:147mmol/L•K+:8mmol/L,Na+:118mmol/L,Cl-:80mmol/L,Glu:33mmol/L•urinalysis:ketone:3+,gravity:1.024,glu:4+第二页，共三十一页。problem•whatisthediagnosis•whatisthereasonofhyperkalemiaandhyponatremia•whatisthereasonofMetabolicacidosis•howtodisposethediseaseifyouaretheERdoctoroncall第三页，共三十一页。IntroductionDKAisasyndromeinwhichinsulindeficiencyandglucagonexcesscombinetoproduceahyperglycemic,dehydrated,acidoticpatientwithprofoundelectrolyteimbalance第四页，共三十一页。PathophysiologyLiverMuscleAdiposetissueGluconeogenesisKetogenesisGlucoseUtilizationLipolysisInsulin↓↓↑↓Glucagon↑↑→→Epinephrine↑↑↓↑Cortisol↑↑↓↑Grownthhormone→↑↓↑第五页，共三十一页。Pathophysiology第六页，共三十一页。Pathophysiology•Insulindeficiencyandglucagonelevationresultsinhyperglycemia,whichinturncauseglycosuria•Glucoseintherenaltubulesdrawswater,sodium,potassium,magnesium,calcium,phosphorus,andotherionsfromthecirculationintotheurine•ThisosmoticdiuresiscombinedwithpoorintakeandvomitingproducestheprofounddehydrationandelectrolyteimbalanceassociatedwithDKA•Asaresultofacidosisanddehydration,however,theinitialreportedvaluesfortheseelectrolytesmaybehigherthanactualbodystores.第七页，共三十一页。Pathophysiology•Insulindeficiencyresultsinactivationoflipasethatincreasescirculatingfreefattyacid(FFA)levels.•Long-chainFFAs,nowcirculatinginabundanceasaresultofinsulindeficiency,arepartiallyoxidizedandconvertedinthelivertoacetoacetateandβ-hydroxybutyrate.•ThisalterationoflivermetabolismtooxidizeFFAstoketonesratherthanthenormalprocessofre-esterificationtotriglyceridesappearstocorrelatedirectlywiththealteredglu...
