Simulated Patient Scenario

Diabetic Ketoacidosis (DKA)

Scenario Details

Scenario: Diabetic Ketoacidosis (DKA)

Simulated Patient: 24-year-old Male

Actor/Actress: Student Actor (Patient), Student Actor (Flatmate)

MDT Information

Urgent Response - Unwell Person / Altered Consciousness
24-year-old male, known diabetic, found unwell by flatmate
Reported confusion, vomiting, rapid breathing
Patient is conscious but drowsy
Location: Apartment

On Arrival

You arrive at an apartment where a concerned flatmate meets you. They lead you to the patient's bedroom. The patient, a 24-year-old male, is lying in bed, appearing lethargic and unwell. His breathing is rapid and deep, and you notice a faint fruity odour on his breath as you approach. A vomit bucket is next to the bed. The patient looks flushed and his skin appears dry.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Acutely unwell, lethargic, tachypnoeic, signs of dehydration.
Response	Drowsy, responds to voice but slow and slightly confused. (AVPU = V)
Airway	Clear and self-maintaining. Fruity odour noted.
Breathing	Rapid, deep, sighing respirations (Kussmaul's breathing). Rate elevated.
Circulation	Skin flushed, warm centrally but peripheries may be cool. Mucous membranes dry. Tachycardic. Cap refill may be slightly delayed.
Disability	Altered mental state (drowsy, confused).
Exposure/Environment	Indoor bedroom. Patient wearing pyjamas. Check for insulin pens, glucose meter, signs of infection.

Secondary Survey and Simulation Progression

History (obtained from patient - may be difficult, and flatmate)

Allergies	NKDA
Medications	Insulin (e.g., Novorapid and Lantus - patient unsure of doses today). Maybe Paracetamol.
Past Medical History	Type 1 Diabetes Mellitus (diagnosed age 14). Occasional previous high BGLs, one previous DKA admission 3 years ago. Otherwise generally well.
Last Oral Intake	Flatmate reports patient hasn't eaten much today. Patient vaguely recalls drinking water earlier but has been vomiting for several hours.
Events Preceding	Flatmate reports patient had 'flu-like symptoms' (cough, feeling feverish) starting 2 days ago. Patient admits to poor BGL monitoring recently and possibly missing some insulin doses due to feeling unwell/not eating. Started feeling increasingly thirsty, nauseous yesterday. Vomiting started overnight. Complaining of abdominal pain. Became progressively more lethargic and confused today. Flatmate became concerned and called.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	30 (deep, Kussmaul's)
Lung Sounds (L/R)	Clear bilaterally, good air entry despite altered pattern.
SpO2 (%)	96% (Room Air)
EtCO2 (mmHg)	Low (e.g., 20-25 mmHg) - If available, indicates respiratory compensation for metabolic acidosis.
Pulse Rate (/min.)	125, regular but may feel weak peripherally
CRT (sec.)	3-4 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Sinus Tachycardia. May show peaked T waves if hyperkalaemic (less common initially). Check for underlying ischaemia.
BP (mmHg)	95/60 (Hypotensive due to dehydration)
Skin	Flushed, dry mucous membranes, decreased skin turgor.
Pain (/10)	Reports generalised abdominal pain (5/10).
GCS (/15: E,V,M)	13/15 (E3 - opens eyes to voice, V4 - confused, M6 - obeys commands)
BGL (mmol/L)	HIGH (e.g., 28.5 mmol/L or reads "HI" on meter)
Ketones	Blood ketones HIGH (e.g., >3.0 mmol/L) if meter available. Urine ketones strongly positive (if tested).
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive (PERL)
Temp. (°C)	37.8 (May be normal, low, or slightly elevated despite infection)

Physical Examination

General Appearance: Acutely unwell, lethargic, dehydrated.
Respiratory: Kussmaul's respirations (deep, sighing pattern). Tachypnoea. Clear lungs on auscultation. Fruity (acetone) odour on breath.
Cardiovascular: Tachycardia. Hypotension. Peripheral pulses may be weak. Delayed capillary refill. Dry mucous membranes, poor skin turgor.
Abdomen: May be diffusely tender on palpation. Bowel sounds may be hypoactive.
Neurological: Altered mental status (drowsiness, confusion). GCS 13. Moving all limbs.
Other: Look for potential sources of infection (e.g., respiratory symptoms, signs of UTI - though history is key here). Check injection sites.

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE): Ensure patent airway. Assess breathing adequacy despite Kussmaul's pattern. Assess circulatory status (hypotension, tachycardia). Assess neurological status (GCS, BGL, Ketones).
Oxygen Therapy: Apply oxygen via non-rebreather mask if SpO2 <94% or signs of significant respiratory distress/shock, otherwise nasal prongs may suffice depending on SpO2.
Vascular Access: Establish large-bore IV access (x2 if possible).
Fluid Resuscitation: **Crucial intervention.** Administer intravenous fluids (e.g., Sodium Chloride 0.9%) aggressively according to local protocols for DKA/dehydration/shock. Typically start with 1000mL bolus over 30-60 mins for adults (adjust based on patient condition, age, comorbidities, and local guidelines). Reassess frequently.
Monitoring: Continuous ECG monitoring. Frequent vital signs reassessment (every 5-15 mins). Monitor mental status closely. Recheck BGL periodically.
Investigations: Obtain BGL and blood ketone level (if available).
Do NOT administer insulin pre-hospitally (unless specifically directed by medical control and local protocols, which is rare - fluid resuscitation is the priority).
Manage Nausea/Vomiting: Consider antiemetic (e.g., Ondansetron) if available and indicated.
Identify Precipitant: Consider potential triggers (infection, missed insulin, stress).
Transport: Urgent transport to an Emergency Department capable of managing DKA. Pre-notify receiving hospital (suspected DKA, vitals, BGL/ketones, fluids commenced).
Teamwork & Communication: Clear roles, effective communication with partner and flatmate. Calm reassurance to patient. Clear handover to ED.

Debrief Focus Points

Recognizing the clinical presentation of DKA (hyperglycaemia, ketones, acidosis signs like Kussmaul's breathing, dehydration).
Understanding the pathophysiology of DKA (insulin deficiency, counter-regulatory hormones, dehydration, acidosis).
Prioritizing management steps: ABCDE, IV access, aggressive fluid resuscitation.
Importance of BGL and ketone measurement.
Rationale for withholding prehospital insulin in most cases.
Recognizing potential DKA precipitants.
Importance of frequent reassessment and monitoring.
Effective communication and pre-notification.