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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
Q

Explain how Acidosis is caused in DKA?

A
  1. FFA metabolism due to Absolute/Relative Insulin deficiency
  2. Acidosis caused by ketone body accumulation
  • Can be terminated by insulin
26
Q

What are the main symptoms of DKA?

A
  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
Q

What Fluids and Electrolytes are lost?

A 
Water (6-8 litres)
Sodium (500-1000 mmol)
Chloride (350)
Potassium (500-1000)
Calcium
Phosphate
Magnesium
28
Q

What can precipitate DKA?

A
  1. Omitted Insulin
  2. Pregnancy
  3. Infection
  4. MI
  5. Intoxication/Drugs
29
Q

How do we diagnose DKA?

A
  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
Q

How can CBG show low Glucose levels during DKA diagnosis?

A

Euglycemic Ketosis

Alcoholic Ketosis

31
Q

What investigations can be done for DKA?

A
  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
Q

*How do we assess the severity of DKA? Give EIGHT Criteria

A
  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
Q

How should a DKA patient be managed?

A
  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
Q

What is usually given in Fluid Therapy?

A

Sodium Chloride 0.9%

5 or 10% Glucose

35
Q

How much Sodium chloride is given in Fluid Therapy

A 
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
Q

How much Glucose is given in Fluid Therapy?

A
  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
Q

Potassium given LATER for Fluid Therapy, what levels of Glucose requires K?

A
  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
Q

When should you give Insulin on admission?

A

If the patient is known to be diabetic, continue their normal long acting insulin

39
Q

What is the usual dose for the fixed rate of IV Insulin infusion?

A

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
Q

What is the most commonest cause of death from DKA in children?

A

Cerebral Oedema

41
Q

How is Cerebral Oedema treated?

A

Dexamethasone or Mannitol

42
Q

What should be provided to DKA patients upon recovery?

A
  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
Q

Who provides the Education in self-care for DKA patients?

A

Diabetes Nurse Specialist

44
Q

What are the main things associated with Hyperosmolar Hyperglycaemic Syndrome?

A
  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
Q

How do we treat HHS?

A
  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
Q

Why do we not give Insulin for HHS?

A

Rapid shifts in glucose can cause rapid fluid/sodium shifts and risks Central Pontine Myelinolysis (CPM)

47
Q

What advice can you give to those who is ill and on insulin?

A
  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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