28: Diabetic Emergencies - Dodge Flashcards
DKA type 1 ___ type 2
> > >
describe pathophysiology of DKA
- due to relative or absolute insulin deficiency
- elevated glucagon, cortisol, growth hormones
increased glucagon:insulin ration
DKA
this causes increased gluconeogenesis, glycogenolysis and ketone body formation
decreased GLUT4 –>
decrease glucose into cell
- decreased glucose metabolism in skeltal muscle and fat
- increased reliance on alt fuel sources
increased glucagon, decreased insulin –>
pyruvate –> gluconeogenesis
increased glycogenolysis
describe ketoacidosis
- 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
___ beta-hydroxybutyrate: acetoacetate
3:1 ketone body formation
both can be detected by available assays
urine acetoacetate preferentially
key presentations of DKA
abdominal tenderness
kussmaul/tachypnea respirations
tachycardia
decreased urine output
altered mental status
diagnostic criteria for DKA (4)
- 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
anion gap will be _______ with DKA
normal is 10-12
increased
due to increased ketoacids which neutralized bicarb; potentially from lactic acidosis as well
the work up of DKA is incomplete without…
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
the “I”s of DKA
infection infarction/Ischemia Intoxication Impregnation Idiocy - no meds
what will you order when you suspect DKA?
- 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
3 key DKA treatments
- fluid resuscitation
- insulin treatment
- electrolytes
DKA: replace fluids initially with __
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
_____ REQUIRED to reverse/treat DKA
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
DKA: potassium levels are _____; sodium levels are _
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
DKA considered resolved when (4)
- 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
HHS =
hyperglycemic hyperosmolar syndrome
type 2 _____ type 1 with HHS
> > >
higher mortality than DKA
what is the pathophysiology of HHS/
- due to relative insulin deficiency or inadequate fluid intake
- deficient insulin = increased hepatic glucose production
- hyperglycemia leads to somotic diuresis = dehyrdatation
HHS: believed that _____ _______ deficiency leads to less counter regulator hormones and therefor no ketoacid production
relative insulin
symptoms of HHS
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
diagnostic criteria HHS
- serum glucose > 600
- hyperosmolarity: osmolality > 350
- elevated BUN and creatinine often
- no/mild acidosis and ketoacidosis
potential cases of HHS …
stroke
MI
infection/sepsis
decreased fluid intake
treatment for HHS (3)
1 fluid resuscitation
- insulin
- electrolytes
what fluid would you give to an HHS pt?
- bolus with 0.9% NaCl to stabilize hemodynamics
- monitor electrolytes with volume replacement
what is the insulin treatment for HHS?
- bolus 0.1 units/kg, then 0.1 units/kg/hr infusion
continue until glucose improved and eating, then subcutaneous
what do the electrolytes look like with HHS?
- monitor K and replace with tx of hyperglycemia
- Na may be elevated to to dehydration
define hypoglycemia
serum glucose less than 70 mg/dL
usually has increased catecholamines and glucagon
symptoms of hypoglycemia
tremor, palpitations, anxiety
tachycardia, sweating, parasthesias
seizure and coma are possible when severe
severe tx for hypoglycemia
admission with infusion of dextrose containing fluids until insulin effect has worn off
glucagon injection can be considered
