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Yr3 Met 3B > 2. Diabetic Emergencies > Flashcards

2. Diabetic Emergencies Flashcards

1
Q

What concentration of glucose can you expect symptoms to arise in Hypoglycemics?

A

3.6 mmol/L (Four’s the Floor)

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2
Q

What is False Hypoglycemia

A

Patients with consistently high glucose levels can experience symptoms at a higher level than someone with good glycemic control

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3
Q

Give 5 causes for Hypoglycemia

A
  1. Alcohol
  2. Vomiting
  3. Breastfeeding
  4. Exercise with High Insulin/Low Carbs
  5. Imbalance of Insulin/Carbs/Sulfonylurea Therapy
  6. Others
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4
Q

What main Medical conditions can cause Hypoglycemia?

A
  1. Liver Disease
  2. Progressive Renal Impairment
  3. Hypoadrenalism
  4. Hypothyroidism
  5. Hypopituitarism
  6. Insulinoma
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5
Q

What are the Autonomic Symptoms of Hypoglycemia and when do they occur?

A
  1. Sweating
  2. Palpitations
  3. Anxiety
  4. Nausea
  5. Shaking/Tremor
  6. Hunger

3.6 mmol/L

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6
Q

What are the Neuroglycopenic Symptoms of Hypoglycemia and when do they occur?

A
  1. Slurred Speech
  2. Confusion
  3. Aggression
  4. Drowsiness
  5. Visual Disturbances
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7
Q

What can be the risks of Hypoglycemia Unawareness?

A
  1. Increased risk of Severe Hypo
  2. Increased risk of Death (Dead in Bed)
  3. Increased risk of Road traffic accidents
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8
Q

What can cause Hypoglycemia Unawareness?

A
  1. Increased duration of diabetes
  2. Tight Glycemic control
  3. Autonomic neuropathy
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9
Q

How can we reverse Hypoglycemia unawareness?

A
  1. Hypo Holiday
  2. Strict Hypoglycemia avoidance by relaxing glycemic control
  3. Continuous SC Insulin Infusion (Insulin Pump Therapy)
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10
Q

How would a Mild Hypoglycemic Patient present?

A

Conscious, Lucid and can Self-Treat

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11
Q

How would a Moderate Hypoglycemic Patient present?

A

Conscious but cannot Self-Treat

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12
Q

How would a Severe Hypoglycemic Patient present?

A

Unconscious

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13
Q

How would you treat Mild Hypoglycemic Patients?

A
  1. Sugary Drink (Lucozade/Coke)
  2. 5-7 Glucose Tablets
  3. 3-4 Sugar spoons in water
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14
Q

How would you treat Moderate Hypoglycemic Patients?

A
  1. Glucogel (1-2 Tubes buccally)
    - Jam/Honey/Treacle into cheek
  2. IM Glucagon
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15
Q

How would you treat Severe Hypoglycemic Patients?

A
  1. Recovery position
  2. 0.5-1.0 mg Glucagon IM
  3. Call 999

Hospital:
75 ml of 20% glucose
150 ml of 10% glucose (Both over 15 mins)

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16
Q

Why should you be mindful when giving 50 ml of 50% Glucose?

A

Extravasation in veins can cause chemical burns

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17
Q

After a patient’s Hypoglycemic episode, what can be given for treatment?

A
  1. Two Biscuits
  2. Slice of Bread
  3. 200-300 ml Milk
  4. Normal meal with carbs
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18
Q

For Drivers on insulin, list all the things they must do

A
  1. Inform the DVLA and insurance company
  2. Plan driving in advance
  3. Carry carbs in car
  4. Check BG before driving + every 2 hours
  5. When feeling a hypo, stop at a safe spot and drive only when recovered
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19
Q

What are the symptoms of Nocturnal Hypoglycemia?

A

Waking up with:

  1. High BG (Rebound Hyerglycemia)
  2. Headaches/Hungover feeling
20
Q

How do we confirm Nocturnal Hypoglycemia?

A
  1. Test BG Levels at 3AM
  2. OR Use continuous glucose monitoring sensor (CGMS)
    - SC monitoring of Glucose over 5 days
21
Q

How do we manage Nocturnal Hypoglycemia

A
  1. Pre-bed snack
  2. Analogue Insulin
  3. Change Insulin Timing
  4. Insulin Pump Therapy
22
Q

What is Diabetic Ketoacidosis?

A

State of Absolute/Relative Insulin deficiency, causing Hyperglycemia

Accumulation of Ketoacids in the blood with subsequent Metabolic Acidosis

23
Q

What are the main biochemical symptoms of DKA?

A 
Hyperglycemia
- BG: >14 mmol/L
Acidosis
- pH: <7.3
- Bicarb: <15 mmol/L
Ketosis
- Elevated Serum/Urine Ketones
24
Q

What is the pathogenesis of DKA?

A
  1. Excess Catecholamines
    - Promote TG breakdown to FFA + Glycerol
    - Stimulates GNG
  2. Insulin Deficiency
    - Inhibits GNG
25
Explain how Acidosis is caused in DKA?
1. FFA metabolism due to Absolute/Relative Insulin deficiency 2. Acidosis caused by ketone body accumulation - Can be terminated by insulin
26
What are the main symptoms of DKA?
1. Abdominal Pain 2. Vomiting 3. Kussmaul's Respiration - Deep sighing respiration due to acidosis 4. Ketones on Breath (40% cannot smell it) 5. Drowsiness/Confusion 6. Dehydration 7. Tachycardia
27
What Fluids and Electrolytes are lost?
``` Water (6-8 litres) Sodium (500-1000 mmol) Chloride (350) Potassium (500-1000) Calcium Phosphate Magnesium ```
28
What can precipitate DKA?
1. Omitted Insulin 2. Pregnancy 3. Infection 4. MI 5. Intoxication/Drugs
29
How do we diagnose DKA?
1. Venous Blood Gases show Acidosis - pH <7.35, Bicarb <15 2. CBG over 14 mmol/L but can be lower 3. Raised Urea and Creatinine 4. Raised Urine/Plasma Ketones
30
How can CBG show low Glucose levels during DKA diagnosis?
Euglycemic Ketosis | Alcoholic Ketosis
31
What investigations can be done for DKA?
1. Pregnancy 2. ECG/CXR 3. MSU (Midstream Specimen of Urine) 4. Blood Cultures 5. Biochemical Profile/Lab of Glucose 6. FBC 7. HbA1c
32
*How do we assess the severity of DKA? Give EIGHT Criteria
1. Blood Ketones > 6 mmol/L 2. Bicarbonate < 5 mmol/L 3. pH < 7.1 4. Potassium < 3.5 mmol/L 5. GCS < 12 6. O2 sats < 92% 7. Systolic BP < 90 mmHg 8. Pulse outside of 60-100
33
How should a DKA patient be managed?
1. Level 2 Bed (HDU) 2. Cardiac Monitor 3. NG Tube if impaired consciousness 4. Central Venous Pressure Line 5. Oxygen if PaO2 < 10.5 kPa 6. Urinary Catheter 7. Prophylactic LMW Heparin 8. IV Antibiotics for infection 9. Monitor the Criteria
34
What is usually given in Fluid Therapy?
Sodium Chloride 0.9% 5 or 10% Glucose
35
How much Sodium chloride is given in Fluid Therapy
``` 1 Litre Stat 1 Litre in 1 hour 1 Litre over 2 hours (+20 mmol KCl) 1 Litre over 4 hours (+ KCl) 1 Litre over 4 hours (+KCl) ```
36
How much Glucose is given in Fluid Therapy?
1. Start when the CBG is <12 mmol/L and continue at 125 ml/Hr 2. 10% is necessary to increase insulin infusion 3. Increase infusion rate if the glucose falls below 6 mmol/L
37
Potassium given LATER for Fluid Therapy, what levels of Glucose requires K?
1. For the first two bags of fluid, fluid is given RAPIDLY 2. For every NaCl 0.9% and Glucose 5%, use KCl: <3.5: Needs more K+, delay insulin 3.5-5.5: 20-40 mmol/L >5.5: None
38
When should you give Insulin on admission?
If the patient is known to be diabetic, continue their normal long acting insulin
39
What is the usual dose for the fixed rate of IV Insulin infusion?
IV Syringe Pump with 50 Units Actrapid (50 mL in NaCl 0.9%) - 0.1 U/kg (About 6-8 U/hr for most patients) - Aim for Bicarb rise of 3 mmol/hr - Aim for Glucose fall of 3 mmol/hr If not, increase rate by 1U/hr
40
What is the most commonest cause of death from DKA in children?
Cerebral Oedema
41
How is Cerebral Oedema treated?
Dexamethasone or Mannitol
42
What should be provided to DKA patients upon recovery?
1. Return to usual SC insulin once eating/drinking reliably - Patients will be nauseous/cannot eat until ketones are clear - Ketonuria reflects lack of adequate glucose/insulin 2. Education in self-care and sick-day rules to stop future DKA
43
Who provides the Education in self-care for DKA patients?
Diabetes Nurse Specialist
44
What are the main things associated with Hyperosmolar Hyperglycaemic Syndrome?
1. Type 2 Diabetes 2. Longer Subacute history 3. Hyperglycemia >40 mmol/L 4. Osmolality >340 (275-95) 5. Ketonuria 6. Lactic acidosis 7. Dehydration
45
How do we treat HHS?
1. IV Fluids for DKA but consider slower fluids for elderly/Heart issues 2. NO INSULIN BOLUS/0.45 SALINE - Perhaps low doses after 12 hours (1U/hr) 3. Correct thehir BG at max 2 mmol/L/hr 4. Central Venous Pressure monitoring - In case they need LMWH or K
46
Why do we not give Insulin for HHS?
Rapid shifts in glucose can cause rapid fluid/sodium shifts and risks Central Pontine Myelinolysis (CPM)
47
What advice can you give to those who is ill and on insulin?
1. Drink your fluids 2. Drink sugary fluids if you cannot eat 3. Monitor glucose levels regularly 4. Never stop tablets/insulin

Yr3 Met 3B (13 decks)

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