5. diabetic emergencies Flashcards
what is diabetic ketoacidosis (DKA) characterised by?
hyperglycaemia
metabolic acidosis
hyperketonaemia
(mainly in T1DM)
what is the specific diagnostic criteria (values) for DKA
blood glucose > 11mmol/L (aka diabetes)
blood ketones > 3mmol/L
bicarbonate < 15mmol/L or venous pH < 7.3
what are some main causes of DKA
- infection (e.g. UTI, surgery..)
- poor compliance
- first presentation of type 1 diabetes
- dehydration
- fasting
what is the relevance of potassium in DKA
insulin causes potassium to move INTO cells
-insulin deficiency = move out = high extracellular K = renal K loss = whole body K depletion
what other processes happen with DKA
increased lipolysis with release of NEFA
-NEFA is partially oxidised to ketone bodies = ketonaemia
symptoms of DKA
- polyuria, polydipsia, thirst
- blurred vision
- vomiting
- abdominal pain
- weakness
- leg cramping
- gradual drowsiness and dehydration in T1DM (rarely T2)
signs of DKA
- Kussmal respiration
- ketonic fetor (acetone smell)
- dehydration
- tachycardia
- hypotension
- mild hypothermia
- confusion, drowsiness, coma
how should DKA be confirmed
clinical feature with a blood glucose measurement and blood gas sample (metabolic acidosis with respiratory compensation)
what are the ESSENTIAL early investigations DKA
- capillary blood glucose (>11.1mmol/L)
- Blood (or urinary) ketones (>3mmol/L)
- Urea and eletrolytes
- venous blood gas analysis
- Urinary glucose and ketones
- Blood cultures (if evidence of infection)
- Cardiac monitoring/ECG (any ischaemic changes or changes secondary to hypokalaemia)
what are some other investigations DKA
- glucose, renal profile, FBC, CRP
- ECG
- CXR
- blood culture
- MSU
what is the initial management (i.e. within first hour) of a patient in DKA
- start 0.9% NaCl IV infusion (large bore annular)
- start fixed rate of IV insulin infusion at 0.1 unit/kg/hour. 50 units human soluble insulin made up to 50ml with 0.9% NaCl solution
- assess patient (GCS, RR..)
- further investigations
examples of human soluble insulin (brands)
Actrapid
Humulin S
complications of DKA
*cerebral oedema Adult respiratory distress syndrome (ARDS) /Acute lung injury Pulmonary embolus Arrhythmias Multi-organ failure Co-morbid states
what prophylaxis needs to be considered for DKA
venous thromboembolism
what is Hyperosmolar hyperglycemic state (HHS)
state of severe uncontrolled diabetes
T2DM
-high blood sugar results in high osmolarity without significant ketoacidosis
[[more severe than DKA]]
what is HHS characterised by
– severe hyperglycaemia ≥30mmol/l
– Hyperosmolarity (serum osmolality ≥ 320mosmol/kg
– Hypovolaemia
what is the key difference between HHS and DKA
No significant ketonaemia (serum ketones<3mmol/l) or acidosis (pH>7.3, bicarbonate>15mmol/l)
causing factors of HHS
infection
new onset diabetes
acute illness
non compliance
complications of HHS
– Cerebral oedema
– Osmotic demyelination syndrome (pontine myelinolysis) – Seizures
– Arterial thrombosis MI, CVA, peripheral arterial
– Venous thrombosis (pulmonary embolism)
– Multiorgan failure
– Foot ulceration
– Co-morbid condition
symptoms of HHS
▪Thirst, Polyuria,
▪Blurred vision
▪Weakness
signs of HHS
▪Dehydration ▪Tachycardia ▪Hypotension ▪Confusion & drowsiness ▪Coma
bedside investigations for HHS
– Capillary blood glucose
– Blood ketones (portable ketone meters)
– Urine ketones
– Venous blood gases
what are the values expected of HHS
- Blood glucose ≥30mmol/l
* Blood ketones<3mmol/l or urine ketones 0/trace •Osmolality ≥ 320mosmol/kg
other investigations for HHS
- Glucose/renal profile/FBC
* ECG, CXR, Blood culture, MSU
initial management of HHS
rehydrate slowly with 0.9% saline IVI over 48hrs
- fixed rate IV insulin infusion (0.05units/kg/hr)
- VTE prophylaxis
main differences in HHS
-T2DM
-older
-days/weeks onset
higher mortality
-normal pH, HCO3 and ketones
-glucose >30mmol/L
main differences in DKA
- T1DM (and 2)
- any age esp younger
- rapid onset (<24hrs)
- lower 5% mortality
- pH <7.3
- low HCO3, high ketones
- glucose >11mmol/L
what is hypoglycaemia defined by
glucose <3.5mmol/L
-usually asymptomatic
why does hypoglycaemia occur in diabetes
side effect of treatment
e. g. due to insulin or sulphonureas (anti-diabetic drug)
- suppressed glucose and ketone production
symptoms of hypoglycaemia
- AUTONOMIC: Sweating/ tremor/palpitations
- NEUROGLYCOPENIC SYMPTOMS: Confusion, drowsiness, speech, behaviour, visual disturbance, incoordination, circumoral paraesthesiae
- hunger
treatment of mild hypoglycaemia
- check capillary blood glucose <3.5mmol/L
-oral fast-acting carbohydrate 15-20g
• Lucozade 150-200ml
• Dextrose tablets x 5
• Fruit juice 150-200ml
• Lemonade/coke150-200ml
• Jelly beans (10-15) / Jelly babies 4-5
-wait 10 mins and recheck
treatment of severe hypoglycaemia: if unconscious and unable to safely swallow
- ABCDE
- check cap blood glucose
- IV glucose 20% 75-100ml
- if no IV access: glucagon 1mg sc/im
- wait 10mins and recheck
treatment of severe hypoglycaemia: concious
- check CBG
- treat for mild hypo.
- otherwise glucogel 2 tubes (squeeze between teeth and inner cheek)
- otherwise treat as unconcious
treatment of hypoglycaemia once recovered (post-acute)
- eat 15-20g long acting carb e.g 2 biscuits, one slide of bread
- DO NOT omit insulin injection if due
causes of hypoglycaemia
- too much insulin/sulphonylurea
- too much exercise
- less carbs
- less stress
- change in meds
- renal failure/liver failure/ early pregnancy
