Question: My question is regarding fluid bolus for DKA. There seems to be varying belief on whether or not a DKA patient must be hypotensive to administer a bolus. There is no specific language that I can find addressing bolus protocol for DKA other than the mandatory BHP patch point if the suspected DKA pt is 2-12yrs old, but this is listed under the NaCl fluid bolus protocol where hypotension is a condition for treatment. Just looking for a little clarification on the entire DKA bolus protocol.

 Great question, even though we all know the adult DKA patient is dehydrated, paramedics are not to give fluid boluses unless the DKA patient are actually hypotensive. If you have a long transport time, or will be code 7 for a while or in off load for a while, then the paramedic can consider patching for that specific situation and concern.

It is suggested not to patch for every case, but watch for hypotension.

The exception is children 2 years of age and over, under 12 who even when hypotensive, if they have DKA, then the fluid can hurt them with brain swelling, so you have to patch. The reasoning is that often these kids get very little fluid in the first 12 hours or so while we are caring for them in ER as we regulate their electrolytes. In fact they often receive less than a liter over a longer time frame as we carefully titrate everything in ER/ PICU with the benefit of lab values.

So if you gave them a liter prehsopital in the first few minutes that could be bad for the patient, and not really obvious to paramedics, as the children will look very dry clinically, (because they are). But the fluid shifts can be dangerous to the brain, and so we have to very slow.

Cardiac/Circulation,Intravenous and Fluid Therapy,Patching

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