Predictive Value of Capnography for Suspected Diabetic Ketoacidosis in the Emergency Department
Identifieur interne : 000763 ( Ncbi/Merge ); précédent : 000762; suivant : 000764Predictive Value of Capnography for Suspected Diabetic Ketoacidosis in the Emergency Department
Auteurs : Hassan Soleimanpour [Iran] ; Ali Taghizadieh [Iran] ; Mitra Niafar [Iran] ; Farzad Rahmani [Iran] ; Samad Ej Golzari [Iran] ; Robab Mehdizadeh Esfanjani [Iran]Source :
- Western Journal of Emergency Medicine [ 1936-900X ] ; 2013.
Abstract
Metabolic acidosis confirmed by arterial blood gas (ABG) analysis is one of the diagnostic criteria for diabetic ketoacidosis (DKA). Given the direct relationship between end-tidal carbon dioxide (ETCO2), arterial carbon dioxide (PaCO2), and metabolic acidosis, measuring ETCO2 may serve as a surrogate for ABG in the assessment of possible DKA. The current study focuses on the predictive value of capnography in diagnosing DKA in patients referring to the emergency department (ED) with increased blood sugar levels and probable diagnosis of DKA.
In a cross-sectional prospective descriptive-analytic study carried out in an ED, we studied 181 patients older than 18 years old with blood sugar levels of higher than 250 mg/dl and probable DKA. ABG and capnography were obtained from all patients. To determine predictive value, sensitivity, specificity and cut-off points, we developed receiver operating characteristic curves.
Sixty-two of 181 patients suffered from DKA. We observed significant differences between both groups (DKA and non-DKA) regarding age, pH, blood bicarbonate, PaCO2 and ETco2 values (p≤0.001). Finally, capnography values more than 24.5 mmHg could rule out the DKA diagnosis with a sensitivity and specificity of 0.90.
Capnography values greater than 24.5 mmHg accurately allow the exclusion of DKA in ED patients suspected of that diagnosis. Capnography levels lower that 24.5 mmHg were unable to differentiate between DKA and other disease entities.
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DOI: 10.5811/westjem.2013.4.14296
PubMed: 24381677
PubMed Central: 3876300
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Predictive Value of Capnography for Suspected Diabetic Ketoacidosis in the Emergency Department</title><author><name sortKey="Soleimanpour, Hassan" sort="Soleimanpour, Hassan" uniqKey="Soleimanpour H" first="Hassan" last="Soleimanpour">Hassan Soleimanpour</name><affiliation wicri:level="1"><nlm:aff id="af1-wjem-14-590">Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author><author><name sortKey="Taghizadieh, Ali" sort="Taghizadieh, Ali" uniqKey="Taghizadieh A" first="Ali" last="Taghizadieh">Ali Taghizadieh</name><affiliation wicri:level="1"><nlm:aff id="af2-wjem-14-590">Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author><author><name sortKey="Niafar, Mitra" sort="Niafar, Mitra" uniqKey="Niafar M" first="Mitra" last="Niafar">Mitra Niafar</name><affiliation wicri:level="1"><nlm:aff id="af3-wjem-14-590">Bone Research Center, Endocrine Section, Imam Reza Medical Research & Training Hospital, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Bone Research Center, Endocrine Section, Imam Reza Medical Research & Training Hospital, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author><author><name sortKey="Rahmani, Farzad" sort="Rahmani, Farzad" uniqKey="Rahmani F" first="Farzad" last="Rahmani">Farzad Rahmani</name><affiliation wicri:level="1"><nlm:aff id="af4-wjem-14-590">Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author><author><name sortKey="Golzari, Samad Ej" sort="Golzari, Samad Ej" uniqKey="Golzari S" first="Samad Ej" last="Golzari">Samad Ej Golzari</name><affiliation wicri:level="1"><nlm:aff id="af5-wjem-14-590">Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author><author><name sortKey="Esfanjani, Robab Mehdizadeh" sort="Esfanjani, Robab Mehdizadeh" uniqKey="Esfanjani R" first="Robab Mehdizadeh" last="Esfanjani">Robab Mehdizadeh Esfanjani</name><affiliation wicri:level="1"><nlm:aff id="af6-wjem-14-590">Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24381677</idno><idno type="pmc">3876300</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876300</idno><idno type="RBID">PMC:3876300</idno><idno type="doi">10.5811/westjem.2013.4.14296</idno><date when="2013">2013</date><idno type="wicri:Area/Pmc/Corpus">000782</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000782</idno><idno type="wicri:Area/Pmc/Curation">000782</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Curation">000782</idno><idno 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first="Ali" last="Taghizadieh">Ali Taghizadieh</name><affiliation wicri:level="1"><nlm:aff id="af2-wjem-14-590">Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author><author><name sortKey="Niafar, Mitra" sort="Niafar, Mitra" uniqKey="Niafar M" first="Mitra" last="Niafar">Mitra Niafar</name><affiliation wicri:level="1"><nlm:aff id="af3-wjem-14-590">Bone Research Center, Endocrine Section, Imam Reza Medical Research & Training Hospital, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Bone Research Center, Endocrine Section, Imam Reza Medical Research & Training Hospital, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author><author><name sortKey="Rahmani, Farzad" sort="Rahmani, Farzad" uniqKey="Rahmani F" first="Farzad" last="Rahmani">Farzad Rahmani</name><affiliation wicri:level="1"><nlm:aff id="af4-wjem-14-590">Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author><author><name sortKey="Golzari, Samad Ej" sort="Golzari, Samad Ej" uniqKey="Golzari S" first="Samad Ej" last="Golzari">Samad Ej Golzari</name><affiliation wicri:level="1"><nlm:aff id="af5-wjem-14-590">Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author><author><name sortKey="Esfanjani, Robab Mehdizadeh" sort="Esfanjani, Robab Mehdizadeh" uniqKey="Esfanjani R" first="Robab Mehdizadeh" last="Esfanjani">Robab Mehdizadeh Esfanjani</name><affiliation wicri:level="1"><nlm:aff id="af6-wjem-14-590">Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</nlm:aff><country xml:lang="fr">Iran</country><wicri:regionArea>Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz</wicri:regionArea><wicri:noRegion>Tabriz</wicri:noRegion></affiliation></author></analytic><series><title level="j">Western Journal of Emergency Medicine</title><idno type="ISSN">1936-900X</idno><idno type="eISSN">1936-9018</idno><imprint><date when="2013">2013</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Introduction:</title><p>Metabolic acidosis confirmed by arterial blood gas (ABG) analysis is one of the diagnostic criteria for diabetic ketoacidosis (DKA). Given the direct relationship between end-tidal carbon dioxide (ETCO<sub>2</sub>), arterial carbon dioxide (PaCO<sub>2</sub>), and metabolic acidosis, measuring ETCO<sub>2</sub> may serve as a surrogate for ABG in the assessment of possible DKA. The current study focuses on the predictive value of capnography in diagnosing DKA in patients referring to the emergency department (ED) with increased blood sugar levels and probable diagnosis of DKA.</p></sec><sec><title>Methods:</title><p>In a cross-sectional prospective descriptive-analytic study carried out in an ED, we studied 181 patients older than 18 years old with blood sugar levels of higher than 250 mg/dl and probable DKA. ABG and capnography were obtained from all patients. To determine predictive value, sensitivity, specificity and cut-off points, we developed receiver operating characteristic curves.</p></sec><sec><title>Results:</title><p>Sixty-two of 181 patients suffered from DKA. We observed significant differences between both groups (DKA and non-DKA) regarding age, pH, blood bicarbonate, PaCO<sub>2</sub> and ETco<sub>2</sub> values (p≤0.001). Finally, capnography values more than 24.5 mmHg could rule out the DKA diagnosis with a sensitivity and specificity of 0.90.</p></sec><sec><title>Conclusion:</title><p>Capnography values greater than 24.5 mmHg accurately allow the exclusion of DKA in ED patients suspected of that diagnosis. Capnography levels lower that 24.5 mmHg were unable to differentiate between DKA and other disease entities.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Cydulka, Rk" uniqKey="Cydulka R">RK Cydulka</name></author><author><name sortKey="Gerald, E" uniqKey="Gerald E">E Gerald</name></author><author><name sortKey="Maloney" uniqKey="Maloney">Maloney</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Eve, D" uniqKey="Eve D">D Eve</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Umpierrez, Ge" uniqKey="Umpierrez G">GE Umpierrez</name></author><author><name sortKey="Kitabchi, Ae" uniqKey="Kitabchi A">AE Kitabchi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Micheal, E" uniqKey="Micheal E">E Micheal</name></author><author><name sortKey="Chansky" uniqKey="Chansky">Chansky</name></author><author><name sortKey="Cary, L" uniqKey="Cary L">L Cary</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Milzman, Dave" uniqKey="Milzman D">Dave Milzman</name></author><author><name sortKey="Jancbar, Tim" uniqKey="Jancbar T">Tim Jancbar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Gholipouri, C" uniqKey="Gholipouri C">C Gholipouri</name></author><author><name sortKey="Golzari, Sej" uniqKey="Golzari S">SEJ Golzari</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Gholipouri, C" uniqKey="Gholipouri C">C Gholipouri</name></author><author><name sortKey="Jafar, R" uniqKey="Jafar R">R Jafar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Salari, Sl" uniqKey="Salari S">SL Salari</name></author><author><name sortKey="Mehryar, H" uniqKey="Mehryar H">H Mehryar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Sarahrudi, K" uniqKey="Sarahrudi K">K Sarahrudi</name></author><author><name sortKey="Hadju, S" uniqKey="Hadju S">S Hadju</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Panahi, Jr" uniqKey="Panahi J">JR Panahi</name></author><author><name sortKey="Mahmoodpoor, A" uniqKey="Mahmoodpoor A">A Mahmoodpoor</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Deirdre, M" uniqKey="Deirdre M">M Deirdre</name></author><author><name sortKey="Fearon" uniqKey="Fearon">Fearon</name></author><author><name sortKey="Dale, W" uniqKey="Dale W">W Dale</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kartal, M" uniqKey="Kartal M">M Kartal</name></author><author><name sortKey="Eray, O" uniqKey="Eray O">O Eray</name></author><author><name sortKey="Rinnert, S" uniqKey="Rinnert S">S Rinnert</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Agus, Ms" uniqKey="Agus M">MS Agus</name></author><author><name sortKey="Alexander, Jl" uniqKey="Alexander J">JL Alexander</name></author><author><name sortKey="Mantell, Pa" uniqKey="Mantell P">PA Mantell</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gilhotra, Y" uniqKey="Gilhotra Y">Y Gilhotra</name></author><author><name sortKey="Porter, P" uniqKey="Porter P">P Porter</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Garcia, E" uniqKey="Garcia E">E Garcia</name></author><author><name sortKey="Abramo, Tj" uniqKey="Abramo T">TJ Abramo</name></author><author><name sortKey="Okada, P" uniqKey="Okada P">P Okada</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Soleimanpour, H" uniqKey="Soleimanpour H">H Soleimanpour</name></author><author><name sortKey="Gholipouri, C" uniqKey="Gholipouri C">C Gholipouri</name></author><author><name sortKey="Salarilak, S" uniqKey="Salarilak S">S Salarilak</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">West J Emerg Med</journal-id><journal-id journal-id-type="iso-abbrev">West J Emerg Med</journal-id><journal-id journal-id-type="publisher-id">WestJEM</journal-id><journal-title-group><journal-title>Western Journal of Emergency Medicine</journal-title></journal-title-group><issn pub-type="ppub">1936-900X</issn><issn pub-type="epub">1936-9018</issn><publisher><publisher-name>Department of Emergency Medicine, University of California, Irvine School of Medicine</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24381677</article-id><article-id pub-id-type="pmc">3876300</article-id><article-id pub-id-type="doi">10.5811/westjem.2013.4.14296</article-id><article-id pub-id-type="publisher-id">wjem-14-590</article-id><article-categories><subj-group subj-group-type="heading"><subject>Emergency Department Operations</subject><subj-group subj-group-type="heading"><subject>Original Research</subject></subj-group></subj-group></article-categories><title-group><article-title>Predictive Value of Capnography for Suspected Diabetic Ketoacidosis in the Emergency Department</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Soleimanpour</surname><given-names>Hassan</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="af1-wjem-14-590"><sup>*</sup></xref><xref ref-type="corresp" rid="c1-wjem-14-590"></xref></contrib><contrib contrib-type="author"><name><surname>Taghizadieh</surname><given-names>Ali</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="af2-wjem-14-590"><sup>†</sup></xref></contrib><contrib contrib-type="author"><name><surname>Niafar</surname><given-names>Mitra</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="af3-wjem-14-590"><sup>‡</sup></xref></contrib><contrib contrib-type="author"><name><surname>Rahmani</surname><given-names>Farzad</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="af4-wjem-14-590"><sup>§</sup></xref></contrib><contrib contrib-type="author"><name><surname>Golzari</surname><given-names>Samad EJ</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="af5-wjem-14-590"><sup>‖</sup></xref></contrib><contrib contrib-type="author"><name><surname>Esfanjani</surname><given-names>Robab Mehdizadeh</given-names></name><degrees>MSc</degrees><xref ref-type="aff" rid="af6-wjem-14-590"><sup>¶</sup></xref></contrib></contrib-group><aff id="af1-wjem-14-590"><label>*</label>Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</aff><aff id="af2-wjem-14-590"><label>†</label>Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</aff><aff id="af3-wjem-14-590"><label>‡</label>Bone Research Center, Endocrine Section, Imam Reza Medical Research & Training Hospital, Tabriz, Iran</aff><aff id="af4-wjem-14-590"><label>§</label>Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran</aff><aff id="af5-wjem-14-590"><label>‖</label>Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</aff><aff id="af6-wjem-14-590"><label>¶</label>Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran</aff><author-notes><corresp id="c1-wjem-14-590">Address for Correspondence: Hassan Soleimanpour, MD. Cardiovasular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. Email: <email>soleimanpourh@tbzmed.ac.ir</email>.</corresp><fn id="fn1-wjem-14-590"><p><italic>Supervising Section Editor:</italic> Eric R. Snoey, MD</p></fn><fn id="fn2-wjem-14-590"><p>Full text available through open access at <ext-link ext-link-type="uri" xlink:href="http://escholarship.org/uc/uciem_westjem">http://escholarship.org/uc/uciem_westjem</ext-link></p></fn></author-notes><pub-date pub-type="ppub"><month>11</month><year>2013</year></pub-date><volume>14</volume><issue>6</issue><fpage>590</fpage><lpage>594</lpage><history><date date-type="received"><day>22</day><month>10</month><year>2012</year></date><date date-type="rev-recd"><day>13</day><month>2</month><year>2013</year></date><date date-type="accepted"><day>02</day><month>4</month><year>2013</year></date></history><permissions><copyright-statement>Copyright © 2013 the authors.</copyright-statement><copyright-year>2013</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/4.0"><license-p><pmc-comment>CREATIVE COMMONS</pmc-comment>This is an open access article distributed in accordance with the terms of the Creative Commons
Attribution (CC BY 4.0) License. See: <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/">http://creativecommons.org/licenses/by-nc/4.0/</ext-link>.</license-p></license></permissions><abstract><sec><title>Introduction:</title><p>Metabolic acidosis confirmed by arterial blood gas (ABG) analysis is one of the diagnostic criteria for diabetic ketoacidosis (DKA). Given the direct relationship between end-tidal carbon dioxide (ETCO<sub>2</sub>), arterial carbon dioxide (PaCO<sub>2</sub>), and metabolic acidosis, measuring ETCO<sub>2</sub> may serve as a surrogate for ABG in the assessment of possible DKA. The current study focuses on the predictive value of capnography in diagnosing DKA in patients referring to the emergency department (ED) with increased blood sugar levels and probable diagnosis of DKA.</p></sec><sec><title>Methods:</title><p>In a cross-sectional prospective descriptive-analytic study carried out in an ED, we studied 181 patients older than 18 years old with blood sugar levels of higher than 250 mg/dl and probable DKA. ABG and capnography were obtained from all patients. To determine predictive value, sensitivity, specificity and cut-off points, we developed receiver operating characteristic curves.</p></sec><sec><title>Results:</title><p>Sixty-two of 181 patients suffered from DKA. We observed significant differences between both groups (DKA and non-DKA) regarding age, pH, blood bicarbonate, PaCO<sub>2</sub> and ETco<sub>2</sub> values (p≤0.001). Finally, capnography values more than 24.5 mmHg could rule out the DKA diagnosis with a sensitivity and specificity of 0.90.</p></sec><sec><title>Conclusion:</title><p>Capnography values greater than 24.5 mmHg accurately allow the exclusion of DKA in ED patients suspected of that diagnosis. Capnography levels lower that 24.5 mmHg were unable to differentiate between DKA and other disease entities.</p></sec></abstract></article-meta></front><floats-group><fig id="f1-wjem-14-590" position="float"><label>Figure 1.</label><caption><p>Flow diagram of study involving patients with suspected diabetic ketoacidosis.</p></caption><graphic xlink:href="wjem-14-590-g001"></graphic></fig><fig id="f2-wjem-14-590" position="float"><label>Figure 2.</label><caption><p>The correlation between pH and ETCO<sub>2</sub> levels in 2 groups (diabetic ketoacidosis [blue], non-DKA [green]).</p></caption><graphic xlink:href="wjem-14-590-g002"></graphic></fig><fig id="f3-wjem-14-590" position="float"><label>Figure 3.</label><caption><p>The correlation between PaCO<sub>2</sub> and ETco<sub>2</sub> levels in two groups (diabetic ketoacidosis (DKA) [blue], non-DKA [green]).</p></caption><graphic xlink:href="wjem-14-590-g003"></graphic></fig><fig id="f4-wjem-14-590" position="float"><label>Figure 4.</label><caption><p>The correlation between HCO<sub>3</sub> and ETco<sub>2</sub> levels in two groups (diabetic ketoacidosis (DKA) [blue], non-DKA [green]).</p></caption><graphic xlink:href="wjem-14-590-g004"></graphic></fig><fig id="f5-wjem-14-590" position="float"><label>Figure 5.</label><caption><p>Receiver operating characteristic curve for sensitivity and specificity of capnography for diagnosis of diabetic ketoacidosis (DKA). ETCO<sub>2</sub>>24.5 mmHg with sensitivity and specificity of 0.90 rules out DKA .</p></caption><graphic xlink:href="wjem-14-590-g005"></graphic></fig><table-wrap id="t1-wjem-14-590" position="float"><label>Table 1.</label><caption><p>Demographics characteristics and laboratory findings of both groups (diabetic ketoacidosis [DKA] and non-DKA).</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="right" valign="middle" rowspan="1" colspan="1"></th><th align="right" valign="middle" rowspan="1" colspan="1">DKA Patients</th><th align="right" valign="middle" rowspan="1" colspan="1">Non DKA patients</th><th align="right" valign="middle" rowspan="1" colspan="1">p-value</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Age (years)</td><td align="right" valign="top" rowspan="1" colspan="1">51.01 ± 18.86</td><td align="right" valign="top" rowspan="1" colspan="1">61.53 ± 16.13</td><td align="right" valign="top" rowspan="1" colspan="1">0.001</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Sex</td><td align="right" valign="top" rowspan="1" colspan="1">23 male</td><td align="right" valign="top" rowspan="1" colspan="1">51 male</td><td align="right" valign="top" rowspan="1" colspan="1">0.454</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Blood sugar levels (mg/dL)</td><td align="right" valign="top" rowspan="1" colspan="1">458.66 ± 193.16</td><td align="right" valign="top" rowspan="1" colspan="1">361.88 ± 92.94</td><td align="right" valign="top" rowspan="1" colspan="1">0.001</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">pH</td><td align="right" valign="top" rowspan="1" colspan="1">7.24 ± 0.13</td><td align="right" valign="top" rowspan="1" colspan="1">7.36 ± 0.07</td><td align="right" valign="top" rowspan="1" colspan="1"><0.0001</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Bicarbonate (mEq/dL)</td><td align="right" valign="top" rowspan="1" colspan="1">12.76 ± 4.00</td><td align="right" valign="top" rowspan="1" colspan="1">21.81 ± 3.61</td><td align="right" valign="top" rowspan="1" colspan="1"><0.0001</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">PaCO<sub>2</sub></td><td align="right" valign="top" rowspan="1" colspan="1">28.99 ± 7.92</td><td align="right" valign="top" rowspan="1" colspan="1">37.93 ± 6.74</td><td align="right" valign="top" rowspan="1" colspan="1"><0.0001</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">ETCO<sub>2</sub></td><td align="right" valign="top" rowspan="1" colspan="1">17.98 ± 5.24</td><td align="right" valign="top" rowspan="1" colspan="1">31.23 ± 5.45</td><td align="right" valign="top" rowspan="1" colspan="1"><0.0001</td></tr></tbody></table></table-wrap><table-wrap id="t2-wjem-14-590" position="float"><label>Table 2.</label><caption><p>Comparison of the associated symptoms between two groups at admission.</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="right" valign="middle" rowspan="1" colspan="1"></th><th align="right" valign="middle" rowspan="1" colspan="1">All patients</th><th align="right" valign="middle" rowspan="1" colspan="1">DKA patients</th><th align="right" valign="middle" rowspan="1" colspan="1">Non-DKA patients</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Nausea/vomiting</td><td align="right" valign="top" rowspan="1" colspan="1">114 (63%)</td><td align="right" valign="top" rowspan="1" colspan="1">40 (64%)</td><td align="right" valign="top" rowspan="1" colspan="1">74 (62%)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Abdominal pain</td><td align="right" valign="top" rowspan="1" colspan="1">120 (66%)</td><td align="right" valign="top" rowspan="1" colspan="1">45 (72%)</td><td align="right" valign="top" rowspan="1" colspan="1">75 (63%)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Polyuria/polydipsia</td><td align="right" valign="top" rowspan="1" colspan="1">94 (52%)</td><td align="right" valign="top" rowspan="1" colspan="1">39 (63%)</td><td align="right" valign="top" rowspan="1" colspan="1">55 (46%)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">History of diabetes mellitus</td><td align="right" valign="top" rowspan="1" colspan="1">165 (91%)</td><td align="right" valign="top" rowspan="1" colspan="1">46 (74%)</td><td align="right" valign="top" rowspan="1" colspan="1">119 (100%)</td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Fatigue</td><td align="right" valign="top" rowspan="1" colspan="1">172 (95%)</td><td align="right" valign="top" rowspan="1" colspan="1">62 (100%)</td><td align="right" valign="top" rowspan="1" colspan="1">11 (92%)</td></tr></tbody></table><table-wrap-foot><fn id="tfn1-wjem-14-590"><p><italic>DKA</italic>, diabetic ketoacidosis</p></fn></table-wrap-foot></table-wrap></floats-group></pmc><affiliations><list><country><li>Iran</li></country></list><tree><country name="Iran"><noRegion><name sortKey="Soleimanpour, Hassan" sort="Soleimanpour, Hassan" uniqKey="Soleimanpour H" first="Hassan" last="Soleimanpour">Hassan Soleimanpour</name></noRegion><name sortKey="Esfanjani, Robab Mehdizadeh" sort="Esfanjani, Robab Mehdizadeh" uniqKey="Esfanjani R" first="Robab Mehdizadeh" last="Esfanjani">Robab Mehdizadeh Esfanjani</name><name sortKey="Golzari, Samad Ej" sort="Golzari, Samad Ej" uniqKey="Golzari S" first="Samad Ej" last="Golzari">Samad Ej Golzari</name><name sortKey="Niafar, Mitra" sort="Niafar, Mitra" uniqKey="Niafar M" first="Mitra" last="Niafar">Mitra Niafar</name><name sortKey="Rahmani, Farzad" sort="Rahmani, Farzad" uniqKey="Rahmani F" first="Farzad" last="Rahmani">Farzad Rahmani</name><name sortKey="Taghizadieh, Ali" sort="Taghizadieh, Ali" uniqKey="Taghizadieh A" first="Ali" last="Taghizadieh">Ali 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