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Y2 INFLAMMATION > 5. diabetic emergencies > Flashcards

5. diabetic emergencies Flashcards

1
Q

what is diabetic ketoacidosis (DKA) characterised by?

A

hyperglycaemia
metabolic acidosis
hyperketonaemia
(mainly in T1DM)

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2
Q

what is the specific diagnostic criteria (values) for DKA

A

blood glucose > 11mmol/L (aka diabetes)
blood ketones > 3mmol/L
bicarbonate < 15mmol/L or venous pH < 7.3

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3
Q

what are some main causes of DKA

A
  1. infection (e.g. UTI, surgery..)
  2. poor compliance
  3. first presentation of type 1 diabetes
    - dehydration
    - fasting
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4
Q

what is the relevance of potassium in DKA

A

insulin causes potassium to move INTO cells

-insulin deficiency = move out = high extracellular K = renal K loss = whole body K depletion

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5
Q

what other processes happen with DKA

A

increased lipolysis with release of NEFA

-NEFA is partially oxidised to ketone bodies = ketonaemia

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6
Q

symptoms of DKA

A
  • polyuria, polydipsia, thirst
  • blurred vision
  • vomiting
  • abdominal pain
  • weakness
  • leg cramping
  • gradual drowsiness and dehydration in T1DM (rarely T2)
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7
Q

signs of DKA

A
  • Kussmal respiration
  • ketonic fetor (acetone smell)
  • dehydration
  • tachycardia
  • hypotension
  • mild hypothermia
  • confusion, drowsiness, coma
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8
Q

how should DKA be confirmed

A

clinical feature with a blood glucose measurement and blood gas sample (metabolic acidosis with respiratory compensation)

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9
Q

what are the ESSENTIAL early investigations DKA

A
  • 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)
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10
Q

what are some other investigations DKA

A
  • glucose, renal profile, FBC, CRP
  • ECG
  • CXR
  • blood culture
  • MSU
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11
Q

what is the initial management (i.e. within first hour) of a patient in DKA

A
  1. start 0.9% NaCl IV infusion (large bore annular)
  2. 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
  3. assess patient (GCS, RR..)
  4. further investigations
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12
Q

examples of human soluble insulin (brands)

A

Actrapid

Humulin S

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13
Q

complications of DKA

A 
*cerebral oedema 
Adult respiratory distress syndrome (ARDS) /Acute lung
injury
Pulmonary embolus
Arrhythmias
Multi-organ failure
Co-morbid states
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14
Q

what prophylaxis needs to be considered for DKA

A

venous thromboembolism

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15
Q

what is Hyperosmolar hyperglycemic state (HHS)

A

state of severe uncontrolled diabetes
T2DM
-high blood sugar results in high osmolarity without significant ketoacidosis

[[more severe than DKA]]

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16
Q

what is HHS characterised by

A

– severe hyperglycaemia ≥30mmol/l
– Hyperosmolarity (serum osmolality ≥ 320mosmol/kg
– Hypovolaemia

17
Q

what is the key difference between HHS and DKA

A

No significant ketonaemia (serum ketones<3mmol/l) or acidosis (pH>7.3, bicarbonate>15mmol/l)

18
Q

causing factors of HHS

A

infection
new onset diabetes
acute illness
non compliance

19
Q

complications of HHS

A

– 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

20
Q

symptoms of HHS

A

▪Thirst, Polyuria,
▪Blurred vision
▪Weakness

21
Q

signs of HHS

A 
▪Dehydration 
▪Tachycardia 
▪Hypotension 
▪Confusion &amp; drowsiness 
▪Coma
22
Q

bedside investigations for HHS

A

– Capillary blood glucose
– Blood ketones (portable ketone meters)
– Urine ketones
– Venous blood gases

23
Q

what are the values expected of HHS

A
  • Blood glucose ≥30mmol/l

* Blood ketones<3mmol/l or urine ketones 0/trace •Osmolality ≥ 320mosmol/kg

24
Q

other investigations for HHS

A
  • Glucose/renal profile/FBC

* ECG, CXR, Blood culture, MSU

25
Q

initial management of HHS

A

rehydrate slowly with 0.9% saline IVI over 48hrs

  • fixed rate IV insulin infusion (0.05units/kg/hr)
  • VTE prophylaxis
26
Q

main differences in HHS

A

-T2DM
-older
-days/weeks onset
higher mortality
-normal pH, HCO3 and ketones
-glucose >30mmol/L

27
Q

main differences in DKA

A
  • T1DM (and 2)
  • any age esp younger
  • rapid onset (<24hrs)
  • lower 5% mortality
  • pH <7.3
  • low HCO3, high ketones
  • glucose >11mmol/L
28
Q

what is hypoglycaemia defined by

A

glucose <3.5mmol/L

-usually asymptomatic

29
Q

why does hypoglycaemia occur in diabetes

A

side effect of treatment

e. g. due to insulin or sulphonureas (anti-diabetic drug)
- suppressed glucose and ketone production

30
Q

symptoms of hypoglycaemia

A
  • AUTONOMIC: Sweating/ tremor/palpitations
  • NEUROGLYCOPENIC SYMPTOMS: Confusion, drowsiness, speech, behaviour, visual disturbance, incoordination, circumoral paraesthesiae
  • hunger
31
Q

treatment of mild hypoglycaemia

A
  1. 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

32
Q

treatment of severe hypoglycaemia: if unconscious and unable to safely swallow

A
  • ABCDE
  • check cap blood glucose
  • IV glucose 20% 75-100ml
  • if no IV access: glucagon 1mg sc/im
  • wait 10mins and recheck
33
Q

treatment of severe hypoglycaemia: concious

A
  • check CBG
  • treat for mild hypo.
  • otherwise glucogel 2 tubes (squeeze between teeth and inner cheek)
  • otherwise treat as unconcious
34
Q

treatment of hypoglycaemia once recovered (post-acute)

A
  • eat 15-20g long acting carb e.g 2 biscuits, one slide of bread
  • DO NOT omit insulin injection if due
35
Q

causes of hypoglycaemia

A
  • too much insulin/sulphonylurea
  • too much exercise
  • less carbs
  • less stress
  • change in meds
  • renal failure/liver failure/ early pregnancy

Y2 INFLAMMATION (8 decks)

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