Supraventricular Tachycardia With Underlying Atrial Flutter in a Diabetic Ketoacidosis Patient

d iabetic ketoacidosis (DKA) is one of the most common complications in adolescents and young adults with type 1 diabetes. Type 1 diabetes with childhood onset has an incidence that fluctuates from 0.1 to 57.6 per 100,000 and is on the rise (1). In children with type 1 diabetes, the incidence of DKA has been reported to be >30% (2). In a study conducted by Dabelea et al. (3), a higher prevalence of DKA was reported in patients who were younger, male, or of a minority race/ethnicity. Complications of DK A are multiple and include electrolyte disturbances , acute kidney failure, and respiratory distress. The most serious DKA complication is cerebral edema (4). The incidence of cerebral edema in DKA patients is 1%, but the associated mortality rate is 20–25% (5–7). Although electrolyte abnormalities are common, arrhythmias are a rare complication of DKA. We report here the case of a 12-year-old girl who presented with DKA and subsequently developed supraven-tricular tachycardia (SVT) with an underlying atrial flutter rhythm. A 12-year-old girl with a known history of type 1 diabetes presented with altered mental status of 1 day's duration. The event was precipitated by the consumption of a large quantity of sugar-sweetened beverages. Her vital signs in the emergency department showed a respiratory rate of 32 breaths/min, heart rate of 204 bpm, and blood pressure of 135/115 mmHg. The patient was tachycardic with Kussmaul respirations and lethargic , and she only responded to deep painful stimuli. Although the patient was diagnosed with type 1 diabetes at the age of 10 years and had experienced previous episodes of DKA, cardiac abnormalities had never occurred before. Except for a maternal great grandmother with type 2 diabetes, her family history was noncontributory. The patient received 2,000 mL of normal saline boluses and 2 units of regular insulin in the emergency department. Initial laboratory tests revealed a glucose concentration of >600 mg/dL, pH of 6.91, partial pressure of carbon dioxide (PCO 2) of 13.4 mmHg, partial pressure of oxygen of 337 mmHg, and bicar-bonate of 2.7 mmol/L. After being transferred to the pediatric intensive care unit, additional laboratory tests revealed a glucose of 1,005 mg/dL, potassium of 5.2 mEq/L, calcium of 8.6 mgl/dL, blood urea nitrogen of 37 mg/dL, C-reactive protein of 1.5 mg/dL, lactic acid level of 3.4 mmol/L, and A1C of 9.3%. Urinalysis was significant for 3+ glucose , 3+ ketones, and 1+ …