Fatal incident prompts call for better GP education on emergency management of DKA

A fatal case of untreated diabetic ketoacidosis has prompted a coroner to urge the Australian Diabetes Society to provide education to ensure GPs are better able to recognise and manage hyperglycaemic emergencies.

The Victorian coroner found that in a 2019 incident, a 62 year old man, Mr Phillip John Sealey,  died of diabetic ketoacidosis at his home after visiting a GP with symptoms of diabetes but not having a fingerprick glucose test.

The man who had no previous history of diabetes, told the GP at the Nightingale Clinic, Maryborough, that he had experienced symptoms of  thirst urinary frequency and nocturia in the previous three weeks. His family said the man had been very unwell with blurred vision, dizziness and vomiting, but these were not recorded by the GP.

The doctor considered a differential diagnosis of diabetes mellitus but did not think it was necessary to perform a glucose test during the consultation as  he claimed Mr Sealey did not seem grossly unwell.

Instead he ordered pathology testing for the following day, including a fasting blood glucose test, and advised the patient he should be reviewed in a week, following the blood tests.

The GP said he did not consider diabetic ketoacidosis because the patient did not appear to be severely unwell, did not appear to be dizzy and had no signs of acute abdomen on examination.

Mr Sealey returned home with his wife, but his condition deteriorated, with constant vomiting, until his family called an ambulance that evening. The patient became unresponsive and was pronounced dead when the paramedics arrived.

A post mortem found that the patient had severe hyperglycaemia and ketoacidosis. The coroner commented that early identification of the markedly elevated blood glucose at the time of Phillip’s consultation might have prompted testing for ketones and conceivably led to the earlier identification of his evolving ketoacidosis and referral for further testing and management in a hospital setting.

The doctor said he was surprised to learn about the cause of death given the patient’s age and  there was no documented diagnosis of diabetes. He told the inquest that he expressed his condolences to the family and said that he had learned to be even more vigilant in assessing patients without a diagnosis of diabetes but with symptoms of it.

“Should a similar scenario present to himself in the future, he would try to utilise what equipment was available if clinically indicated, including fingerprick blood sugar level test and urinalysis to expedite diagnosis and appropriate care,” the coroner said.

However the coroner noted that previous fatal cases of undiagnosed diabetic ketoacidosis in primary care settings had led to recommendations adopted by the RACGP and the Australian Diabetes Society (ADS) to provide educational updates to GPs on the recognition and management of diagnosis of glycaemic emergencies in the community.

In May 2018, RACGP and ADS produced a joint clinical position statement that “outlined the importance of urgent point-of-care assessment for potential hyperglycaemic crises and sets out the best practice standards of care and preferred methods of assessing blood glucose and ketone including capillary (finger prick) blood glucose and capillary blood ketones. It also includes action flow charts for GPs to assist them in recognising and managing hyperglycaemic emergencies.”

However, the tragic death that occurred after the release of this statement showed that further educational measures were needed, the coroner advised.

The coroner concluded: “I recommend that the RACGP liaise with the Australian Diabetes Society with a view to identifying further opportunities to educate and raise awareness amongst primary care providers about:

  1. Hyperglycaemia emergencies occurring as the first presentation of undiagnosed diabetes;
  2. Identifying and recognising signs and symptoms of an emerging metabolic crises, particularly in patients not known to have diabetes;
  3. Undertaking urgent point-of-care assessment using preferred methods of capillary (finger prick) blood glucose level and capillary blood ketones tests where there are symptoms suggestive of diabetes and/or an emerging metabolic crises;
  4. Adopting best practice standards of care and ensuring they have access to capillary blood glucose and ketone monitoring meters and strips to undertake urgent point-of-care assessment; and
  5. Providing education to patients who are under investigation for or suspected to have diabetes (and their families or carers), about the risk factors, signs and symptoms of glycaemic emergencies and the need to obtain urgent medical assessment and management if such symptoms develop.”

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