2 - diabetic emergencies Flashcards

1
Q

what is diabetic ketoacidosis?

A

disordered metabolic state usually in context of absolute or relative insulin deficiency accompanied by increase in counter-regulatory hormones e.g. glucagon, adrenaline, cortisol, growth hormone

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2
Q

what are causes of DKA?

A
  1. increased insulin deficiency e.g. missed dose, new diagnosis, high carbs
  2. increased in insulin demand, 5 I’s:
    - infections = pneumonia
    - inflammatory = pancreatitis
    - intoxication = alcohol, drugs
    - infarction = MI, stroke
    - iatrogenic = steroids, surgery
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3
Q

what is the triad of pathophysiology causing DKA?

A

triad = hyperglycaemia, ketosis, acidosis

insulin usually inhibits lipolysis (reducing risk of ketone body overload)

= problem is missed insulin as high glucose remains high but insulin not there to help glucose get into cells to be used for energy so body resorts to breakdown of fats & amino acids = means ketones and overload of sugars in blood

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4
Q

what is difference with starvation ketoacidosis? (just to note)

A

when glucose not available body uses lipolysis and free fatty acids to provide energy - means ketones made as by product

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5
Q

how does DKA lead to significant dehydration?

A

lots of glucose excreted via PCT (proximal convoluted tubules) = glycosuria, osmotic diuresis follows as water & electrolytes leave with glucose = dehydration

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6
Q

what are symptoms & signs of diabetic ketoacidosis?

A
  • osmotic related = polyuria & dehydration & thirst
  • ketone related = flushed, vomiting, increased HR, sweet smell, abdo pain, kussmaul breathing (deep, rapid)
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7
Q

how do ketone bodies cause
a) nausea & vomiting
b) kussmaul breathing
c) arrhythmias

A

a) ketones trigger chemotrigger zone in medulla
b) ketone bodies release H+ making acidotic blood, act on peripheral chemoreceptors to increase resp rate to breathe off CO2 & acetone (sweet smell)
c) as H+ ions made, K+ pushed out to maintain balance and then once try to fix with insulin K+ can’t get back in so arrhythmias, palpitations & IBS

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8
Q

what are biochemical results for diabetic ketoacidosis?

A
  • hyperglycaemia (above 11 mmol)
  • ketonaemia (above 3 mmol)
  • acidotic, low bicarb low pH

*also could dp FBCs, U&Es, LFTs (amylase)

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9
Q

what are complications of DKA?

A
  1. hypo or hyperkalemia = arrhythmias
  2. cerebral oedema
  3. pulmonary infiltrates (ARDS)
  4. gastric bubble (from hypocalcemia)
  5. aspiration pneumonia (from vomiting symptom)
  6. DVT or PE since hypercoagulable blood (like fizzy drink on stable is sugar in blood)
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10
Q

what is management of DKA?

A

= close monitoring

  1. correct dehydration (fluids to dilute excess sugar) - should be 3L within hour 4
  2. correct hyperglycemia with insulin
  3. electrolyte imbalance (fluids will lower K+ so give K+ if needed)
  4. identify complications
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11
Q

what is values of ketones?

A

T1DM patients have ketone monitors

  • less than 0.6 is good
  • between 0.6 and 3 suggests starting to develop
  • above 3 is significant ketosis
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12
Q

what is hyperglycaemic hyperosmolar state (HHS)?

A

severe hyperglycemia & hyperosmolarity (normal ketone levels)

  • usually in T2DM when still some production of insulin so enough insulin to prevent lipolysis & ketogenesis but not enough for glucose utilization
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13
Q

what are main causes of HHS?

A
  • consumption of glucose rich fluids
  • trauma or something leading to compromised water intake
  • non compliance with diabetic medications
  • newly diagnosed diabetes
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14
Q

what is presentation of HHS?

A
  • dehydration (due to osmotic imbalance + polyuria)
  • polydipsia (excessive thirst)
  • nausea & vomiting
  • impaired consciousness (depending on osmolarity level)
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15
Q

what is in biochemical diagnosis for HHS?

A
  • hypovolaemia (low fluid)
  • hyperglycaemia (above 30 mmol)
  • normal ketones (below 3)
  • bicarb normal, normal pH
  • osmolality high
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16
Q

how do you calculate osmolality? normal level?

A

2x Na + urea + glucose

normal level is 275-295

17
Q

what are the principles of HHS treatment?

A
  1. plenty fluids, use 0.9% saline for fluid replacement without insulin = key
  2. insulin often not required →plenty fluids might be suitable. start low dose IV insulin ONLY if significant ketones
  3. monitor & chart U&E’s, blood glucose, osmolality, sodium
  4. prophylactic fragmin = heparin (unless contraindicated) - screen for vascular events like MI
  5. identify underlying precipitants
  6. high risk feet complications (CPR = check, protectm refer)- potential source of infection
18
Q

what might cause hypoglycaemia?

A

too much insulin, increased exercise, not eating enough, alcohol (liver prioritises detoxifying alcohol, takes eye off glucose)

note : if you exercise within couple hours eating then like 2 hits of exercise & insulin = high risk of hypoglycaemia

19
Q

what are some symptoms of hypoglycaemia?

A
  • headache
  • hungry
  • sweaty
  • shaky
  • confused
  • dizzy
  • grumpy
  • nausea
  • pallor
20
Q

what is the values for hypoglycaemia?

A

below 4 = hypoglycaemic
below 3 mmol = very serious

severe = has severe cognitive impairment

21
Q

what is hypoglycaemia management?

A

15-20g absorbed carbohydrate (glucose tablet or gel or sugary drink)
*note not choco bar or biscuit when this low as too slow absorption

severe hypoglycaemia = IM glucagon (in community) and IV glucose (in healthcare)

22
Q

what is biochem investigations of alcoholic ketoacidosis?

A

→same presentations as diabetic ketoacidosis but not diabetic so glucose not high

ketonaemia = high, above 3 mmol

bicarb low, below 15 mmol and low pH (below 7.3)

23
Q

what is management of alcoholic ketoacidosis?

A
  • IV pabrinex = high dose vitamins including thiamine to prevent wernicke encephalopathy
  • IV fluid
  • IV anti-emetics
24
Q

how does alcohol cause alcoholic ketoacidosis?

A

drinking after not eating

  • alcohol disrupts glucose production (gluconeogenesis) and depletes glycogen stores in liver by using liver to detoxify the alcohol (alcohol distracts the liver)
  • so body shifts to lipolysis for energy = ketone body production