An elderly male is brought to the emergency department by the police when he was found wandering on the street in the night. He is confused, disoriented, and intermittently complaining of generalized abdominal pain and thirst. Any further history is unobtainable. His blood pressure is 110/80 mmHg, pulse is 98/min, temperature is 36.7C (98 F) and respirations are 22/min. There is no abdominal rigidity or rebound tenderness. Laboratory examination shows that his urine is positive for ketones. His plasma glucose level is 167 mg/dL. Other laboratory results are pending.
What is the best next step in the management of this patient?

Question

An elderly male is brought to the emergency department by the police when he was found wandering on the street in the night.  He is confused, disoriented, and intermittently complaining of generalized abdominal pain and thirst.  Any further history is unobtainable.  His blood pressure is 110/80 mmHg, pulse is 98/min, temperature is 36.7C (98 F) and respirations are 22/min.  There is no abdominal rigidity or rebound tenderness.  Laboratory examination shows that his urine is positive for ketones.  His plasma glucose level is 167 mg/dL.  Other laboratory results are pending.
What is the best next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Most patients with alcoholic ketoacidosis respond to an administration of dextrose normal saline. Insulin is generally not required. Dextrose leads to an increase in insulin secretion, which leads to the metabolism of ketone bodies to bicarbonate. Almost all alcoholics are likely to be thiamine-deficient unless proven otherwise. (Choice B) There is no need to give insulin in patients with alcoholic ketoacidosis. (Choice C)This patient does not have a surgical abdomen; therefore, NPO, ultrasound, and surgical consultation are not required. (Choice D)Discharging the patient after the initial treatment is not an appropriate choice. These patients are likely to develop alcohol withdrawal, electrolyte imbalance and aspiration pneumonia. Furthermore, the administration of glucose can increase the utilization of thiamine, thus aggravating thiamine deficiency and leading to Wernicke' s encephalopathy. (Choice E)IV hydrocortisone is not indicated in the management of alcoholic ketoacidosis. Educational Objective: Most patients with alcoholic ketoacidosis will respond to an administration of intravenous dextrose containing normal saline and thiamine. Insulin is generally not required. All patients need to be hospitalized for treatment.

An Elderly Male Is Brought to the Emergency Department by the Police