2. Diabetic Emergencies Flashcards
What concentration of glucose can you expect symptoms to arise in Hypoglycemics?
3.6 mmol/L (Four’s the Floor)
What is False Hypoglycemia
Patients with consistently high glucose levels can experience symptoms at a higher level than someone with good glycemic control
Give 5 causes for Hypoglycemia
- Alcohol
- Vomiting
- Breastfeeding
- Exercise with High Insulin/Low Carbs
- Imbalance of Insulin/Carbs/Sulfonylurea Therapy
- Others
What main Medical conditions can cause Hypoglycemia?
- Liver Disease
- Progressive Renal Impairment
- Hypoadrenalism
- Hypothyroidism
- Hypopituitarism
- Insulinoma
What are the Autonomic Symptoms of Hypoglycemia and when do they occur?
- Sweating
- Palpitations
- Anxiety
- Nausea
- Shaking/Tremor
- Hunger
3.6 mmol/L
What are the Neuroglycopenic Symptoms of Hypoglycemia and when do they occur?
- Slurred Speech
- Confusion
- Aggression
- Drowsiness
- Visual Disturbances
What can be the risks of Hypoglycemia Unawareness?
- Increased risk of Severe Hypo
- Increased risk of Death (Dead in Bed)
- Increased risk of Road traffic accidents
What can cause Hypoglycemia Unawareness?
- Increased duration of diabetes
- Tight Glycemic control
- Autonomic neuropathy
How can we reverse Hypoglycemia unawareness?
- Hypo Holiday
- Strict Hypoglycemia avoidance by relaxing glycemic control
- Continuous SC Insulin Infusion (Insulin Pump Therapy)
How would a Mild Hypoglycemic Patient present?
Conscious, Lucid and can Self-Treat
How would a Moderate Hypoglycemic Patient present?
Conscious but cannot Self-Treat
How would a Severe Hypoglycemic Patient present?
Unconscious
How would you treat Mild Hypoglycemic Patients?
- Sugary Drink (Lucozade/Coke)
- 5-7 Glucose Tablets
- 3-4 Sugar spoons in water
How would you treat Moderate Hypoglycemic Patients?
- Glucogel (1-2 Tubes buccally)
- Jam/Honey/Treacle into cheek - IM Glucagon
How would you treat Severe Hypoglycemic Patients?
- Recovery position
- 0.5-1.0 mg Glucagon IM
- Call 999
Hospital:
75 ml of 20% glucose
150 ml of 10% glucose (Both over 15 mins)
Why should you be mindful when giving 50 ml of 50% Glucose?
Extravasation in veins can cause chemical burns
After a patient’s Hypoglycemic episode, what can be given for treatment?
- Two Biscuits
- Slice of Bread
- 200-300 ml Milk
- Normal meal with carbs
For Drivers on insulin, list all the things they must do
- Inform the DVLA and insurance company
- Plan driving in advance
- Carry carbs in car
- Check BG before driving + every 2 hours
- When feeling a hypo, stop at a safe spot and drive only when recovered
What are the symptoms of Nocturnal Hypoglycemia?
Waking up with:
- High BG (Rebound Hyerglycemia)
- Headaches/Hungover feeling
How do we confirm Nocturnal Hypoglycemia?
- Test BG Levels at 3AM
- OR Use continuous glucose monitoring sensor (CGMS)
- SC monitoring of Glucose over 5 days
How do we manage Nocturnal Hypoglycemia
- Pre-bed snack
- Analogue Insulin
- Change Insulin Timing
- Insulin Pump Therapy
What is Diabetic Ketoacidosis?
State of Absolute/Relative Insulin deficiency, causing Hyperglycemia
Accumulation of Ketoacids in the blood with subsequent Metabolic Acidosis
What are the main biochemical symptoms of DKA?
Hyperglycemia - BG: >14 mmol/L Acidosis - pH: <7.3 - Bicarb: <15 mmol/L Ketosis - Elevated Serum/Urine Ketones
What is the pathogenesis of DKA?
- Excess Catecholamines
- Promote TG breakdown to FFA + Glycerol
- Stimulates GNG - Insulin Deficiency
- Inhibits GNG
Explain how Acidosis is caused in DKA?
- FFA metabolism due to Absolute/Relative Insulin deficiency
- Acidosis caused by ketone body accumulation
- Can be terminated by insulin
What are the main symptoms of DKA?
- Abdominal Pain
- Vomiting
- Kussmaul’s Respiration
- Deep sighing respiration due to acidosis - Ketones on Breath (40% cannot smell it)
- Drowsiness/Confusion
- Dehydration
- Tachycardia
What Fluids and Electrolytes are lost?
Water (6-8 litres) Sodium (500-1000 mmol) Chloride (350) Potassium (500-1000) Calcium Phosphate Magnesium
What can precipitate DKA?
- Omitted Insulin
- Pregnancy
- Infection
- MI
- Intoxication/Drugs
How do we diagnose DKA?
- Venous Blood Gases show Acidosis
- pH <7.35, Bicarb <15 - CBG over 14 mmol/L but can be lower
- Raised Urea and Creatinine
- Raised Urine/Plasma Ketones
How can CBG show low Glucose levels during DKA diagnosis?
Euglycemic Ketosis
Alcoholic Ketosis
What investigations can be done for DKA?
- Pregnancy
- ECG/CXR
- MSU (Midstream Specimen of Urine)
- Blood Cultures
- Biochemical Profile/Lab of Glucose
- FBC
- HbA1c
*How do we assess the severity of DKA? Give EIGHT Criteria
- Blood Ketones > 6 mmol/L
- Bicarbonate < 5 mmol/L
- pH < 7.1
- Potassium < 3.5 mmol/L
- GCS < 12
- O2 sats < 92%
- Systolic BP < 90 mmHg
- Pulse outside of 60-100
How should a DKA patient be managed?
- Level 2 Bed (HDU)
- Cardiac Monitor
- NG Tube if impaired consciousness
- Central Venous Pressure Line
- Oxygen if PaO2 < 10.5 kPa
- Urinary Catheter
- Prophylactic LMW Heparin
- IV Antibiotics for infection
- Monitor the Criteria
What is usually given in Fluid Therapy?
Sodium Chloride 0.9%
5 or 10% Glucose
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)
How much Glucose is given in Fluid Therapy?
- Start when the CBG is <12 mmol/L and continue at 125 ml/Hr
- 10% is necessary to increase insulin infusion
- Increase infusion rate if the glucose falls below 6 mmol/L
Potassium given LATER for Fluid Therapy, what levels of Glucose requires K?
- For the first two bags of fluid, fluid is given RAPIDLY
- 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
When should you give Insulin on admission?
If the patient is known to be diabetic, continue their normal long acting insulin
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
What is the most commonest cause of death from DKA in children?
Cerebral Oedema
How is Cerebral Oedema treated?
Dexamethasone or Mannitol
What should be provided to DKA patients upon recovery?
- 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 - Education in self-care and sick-day rules to stop future DKA
Who provides the Education in self-care for DKA patients?
Diabetes Nurse Specialist
What are the main things associated with Hyperosmolar Hyperglycaemic Syndrome?
- Type 2 Diabetes
- Longer Subacute history
- Hyperglycemia >40 mmol/L
- Osmolality >340 (275-95)
- Ketonuria
- Lactic acidosis
- Dehydration
How do we treat HHS?
- IV Fluids for DKA but consider slower fluids for elderly/Heart issues
- NO INSULIN BOLUS/0.45 SALINE
- Perhaps low doses after 12 hours (1U/hr) - Correct thehir BG at max 2 mmol/L/hr
- Central Venous Pressure monitoring
- In case they need LMWH or K
Why do we not give Insulin for HHS?
Rapid shifts in glucose can cause rapid fluid/sodium shifts and risks Central Pontine Myelinolysis (CPM)
What advice can you give to those who is ill and on insulin?
- Drink your fluids
- Drink sugary fluids if you cannot eat
- Monitor glucose levels regularly
- Never stop tablets/insulin
