28: Diabetic Emergencies - Dodge

Question 1

DKA type 1 ___ type 2

Answer 1

> > >

Question 2

describe pathophysiology of DKA

Answer 2

• due to relative or absolute insulin deficiency

- elevated glucagon, cortisol, growth hormones

Question 3

increased glucagon:insulin ration

Answer 3

DKA

this causes increased gluconeogenesis, glycogenolysis and ketone body formation

Question 4

decreased GLUT4 –>

Answer 4

decrease glucose into cell

• decreased glucose metabolism in skeltal muscle and fat
• increased reliance on alt fuel sources

Question 5

increased glucagon, decreased insulin –>

Answer 5

pyruvate –> gluconeogenesis

increased glycogenolysis

Question 6

describe ketoacidosis

Answer 6

• increased lipolyiss
• release of FFA
• liver: elevated glucagon leads to increased ketone body formation
• VLDL and triglyceride formation also increased (usual pathway for FFA) but less than ketone bodies

Question 7

___ beta-hydroxybutyrate: acetoacetate

Answer 7

3:1 ketone body formation

both can be detected by available assays

urine acetoacetate preferentially

Question 8

key presentations of DKA

Answer 8

abdominal tenderness

kussmaul/tachypnea respirations

tachycardia

decreased urine output

altered mental status

Question 9

diagnostic criteria for DKA (4)

Answer 9

• serum glucose > 250 mg/dL
• serum bicarb less than 18 mEq/L
• presence of serum ketones (more accurate representation of body ketone levels than urine)
• serum pH less than 7.3

Question 10

anion gap will be _______ with DKA

normal is 10-12

Answer 10

increased

due to increased ketoacids which neutralized bicarb; potentially from lactic acidosis as well

Question 11

the work up of DKA is incomplete without…

Answer 11

attempting to determine inciting event, the WHY

ask about: recent sick contact, illnesses, medication compliance, sexual activity (infection, preggers), cough, fever, sweats, diarrhea, chest pain, drug use

Question 12

the “I”s of DKA

Answer 12

infection
infarction/Ischemia
Intoxication
Impregnation
Idiocy - no meds

Question 13

what will you order when you suspect DKA?

Answer 13

• serum glucose, electrolytes, ketones, ABG
• urinalysis, dipstick for ketones
• EKG (especially if older)
• CBC with diff
• renal function, ELECTROLYTES, liver enzymes
• culture blood urine sputum
• chest xray

Question 14

3 key DKA treatments

Answer 14

1. fluid resuscitation
2. insulin treatment
3. electrolytes

Question 15

DKA: replace fluids initially with __

Answer 15

0.9% NaCl solution

initial bolus of 2-3 liters of fluid over the first 1-3 hrs and reassess as you go

will need to change to 5% dextrose in 0.9% of 0.45% NaCl once serum glucose is less than 200 mg/dL

Question 16

_____ REQUIRED to reverse/treat DKA

Answer 16

insulin

2 options:

• bolus 0.1 unit/kg, then 0.1 units/kg/hr continuous insulin infusion
• 0.14 untis/kg/hr continuous infusion with no bolus

follow serum or fingerstick glucose every hr; once DKA resolved transition to subcutaneous insulin

Question 17

DKA: potassium levels are _____; sodium levels are _

Answer 17

depleted; low

• replace K before starting insulin if less than 3.3 mEq/L
• sodium levels are falsely diluted from hyperlgycemia [psuedohyponatremia], decreases about 1.6 mEq/L for every 100 mg/dL over 100 blood sugar levels

follow electrolytes and renal function every 3-4 hrs during treatment

Question 18

DKA considered resolved when (4)

Answer 18

• serum glucose less than 200
• serum bicarb greater than 15
• serum pH greater than 7.3
• anion gap less than 12

can start subcutaneous insulin at this time; restart home or calculate new dose

Question 19

HHS =

Answer 19

hyperglycemic hyperosmolar syndrome

Question 20

type 2 _____ type 1 with HHS

Answer 20

> > >

higher mortality than DKA

Question 21

what is the pathophysiology of HHS/

Answer 21

• due to relative insulin deficiency or inadequate fluid intake
• deficient insulin = increased hepatic glucose production
• hyperglycemia leads to somotic diuresis = dehyrdatation

Question 22

HHS: believed that _____ _______ deficiency leads to less counter regulator hormones and therefor no ketoacid production

Answer 22

relative insulin

Question 23

symptoms of HHS

Answer 23

less severe, slower onset

• polyuria, weight loss, decreased oral intake
• altered mental status
• dehyrdation with hypotension, tachycardia

NO nausea, vomiting , kussmaul breathing, and abdominal pain

Question 24

diagnostic criteria HHS

Answer 24

• serum glucose > 600
• hyperosmolarity: osmolality > 350
• elevated BUN and creatinine often
• no/mild acidosis and ketoacidosis

Question 25

potential cases of HHS …

Answer 25

stroke
MI
infection/sepsis
decreased fluid intake

Question 26

treatment for HHS (3)

Answer 26

1 fluid resuscitation

• insulin
• electrolytes

Question 27

what fluid would you give to an HHS pt?

Answer 27

• bolus with 0.9% NaCl to stabilize hemodynamics

- monitor electrolytes with volume replacement

Question 28

what is the insulin treatment for HHS?

Answer 28

• bolus 0.1 units/kg, then 0.1 units/kg/hr infusion

continue until glucose improved and eating, then subcutaneous

Question 29

what do the electrolytes look like with HHS?

Answer 29

• monitor K and replace with tx of hyperglycemia

- Na may be elevated to to dehydration

Question 30

define hypoglycemia

Answer 30

serum glucose less than 70 mg/dL

usually has increased catecholamines and glucagon

Question 31

symptoms of hypoglycemia

Answer 31

tremor, palpitations, anxiety

tachycardia, sweating, parasthesias

seizure and coma are possible when severe

Question 32

severe tx for hypoglycemia

Answer 32

admission with infusion of dextrose containing fluids until insulin effect has worn off

glucagon injection can be considered