Internal Medicine Physician Dublin Methodist, Ohio, United States
Introduction: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication usually seen in individuals with type-1 diabetes mellitus that manifests a state of ketonemia and metabolic acidosis. An overlooked complication of DKA is its ability to promote a prothrombotic state, which can lead to cerebrovascular accidents and even acute mesenteric ischemia.
Description: We present a 72-year old male with a history of type 2 diabetes mellitus, hypertension, and atherosclerosis, came to the ED as a category 1 trauma, found down on his bathroom floor for 12-15 hours with unclear loss of consciousness. The patient arrived tachycardic, normotensive, saturating 100% on 4 L nasal cannula with a GCS of 11. Remaining aspects of the primary and secondary survey were all unremarkable. Imaging obtained at that time including chest, pelvic, right lower extremity plain films from hip to ankle, and computed tomography (CT) of the head and vertebral column showed no acute traumatic findings. Labs on admission showed glucose levels of 700 mg/dL, lactate of 9.8, anion gap of 28, bicarbonate of 9, and pH of 7.17 and IV insulin therapy was started. Despite analgesics, aggressive fluid resuscitation, and increasing insulin therapy, he continued to have worsening lactate of 10.6mmol/L, glucose levels of 772 mg/dL, and abdominal pain, which prompted an abdominal CT scan. CT revealed extensive portal venous air and suspected pneumatosis intestinalis indicating potential bowel necrosis leading to a surgery consult for emergent exploratory laparotomy; only 45-50 cm of potentially viable mesentery proximal to the ligament of Treitz was present and thus was not compatible with life.
Discussion: Diabetes is a proven hypercoagulable state with increases in prothrombotic factors and an overall increase in platelet release products. AMI classically presents as “pain out of proportion”, but nausea, vomiting, and abdominal pain are common symptoms seen in DKA as well. However, if even after adequate fluid resuscitation and insulin therapy there is worsening acidosis and abdominal pain, it is important to maintain a high degree of clinical suspicion for AMI. CT angiography is still considered first-line diagnostic evaluation and early identification and intervention is critical to improving patient morbidity and mortality.
