title: Prehospital cardiac arrest in diabetic ketoacidemia: why brain swelling may lead to death before treatment.
abstract: An adolescent is reported with type 1 diabetes mellitus and diabetic ketoacidemia (DKA) who died from brain herniation prior to treatment with intravenous fluids and intravenous insulin. The pathophysiology of raised intracranial pressure (ICP) and water intoxication is discussed. As DKA evolves, water and electrolyte losses are replaced by very hypotonic fluids taken orally, leading to a physiologic excess of free water that would cause brain swelling prior to treatment. Central nervous system acidosis may interfere with normal compensatory mechanisms that help prevent small increases in ICP. The pathophysiology of pre-treatment brain swelling has important implications for rehydration with intravenous fluids and treatment with insulin. Prevention of DKA is paramount as well as complete postmortem evaluation of patients who die from this disease.
authors.affiliation: Department of Pediatrics, Section of Critical Care, 2CH220 Children's Hospital of Eastern North Carolina, East Carolina University Brody School of Medicine, 600 Moye Boulevard, Greenville, NC 27858-4354, USA. fiordalisii@mail.ecu.edu
authors.forename: Irma
authors.initials: I
authors.lastname: Fiordalisi
authors.forename: Glenn D
authors.initials: GD
authors.lastname: Harris
authors.forename: M G F
authors.initials: MG
authors.lastname: Gilliland
mesh_terms: D000293:Adolescent; D001929:Brain Edema / Q000175:diagnosis*; D003922:Diabetes Mellitus, Type 1 / Q000150:complications*; D017809:Fatal Outcome; D005440:Fluid Therapy; D006323:Heart Arrest; D006801:Humans; D007262:Infusions, Intravenous; D007328:Insulin / Q000008:administration & dosage / Q000627:therapeutic use; D019586:Intracranial Hypertension / Q000175:diagnosis*; D008297:Male
chemical_list: D007328:Insulin