A to E: Disability - Hyperglycaemia Flashcards
What is the diagnostic criteria for diabetic ketoacidosis (DKA)?
An emergency diabetes complication, characterised by:
-
Hyperglycaemia >11mmol/L; or known DM
- Euglycaemic DKA can occur with SGLT-2 inhibitors
- Acidosis: bicarb <15mmol/L and/or venous pH <7.3
- Significant ketonuria (2+) or ketonaemia (>3mmol/L)
List five possible triggers of DKA
- Infection
- Discontinuation of insulin; inadequate insulin
- Cardiovascular disease
- Drugs:
- Steroids, sympathomimetics, A-blockers, B-blockers, diuretics, SGAs, SGLT2i
- Stress: Surgery, trauma, pregnancy
- Chemotherapy
What may be the cause of DKA in T2DM?
Side effect of SGLT2 inhibitors
Canagliflozin, Dapagliflozin, Empagliflozin
List three presenting features of DKA
- Initial:
- Polyuria; polydipsia; dehydration
- Vomiting; abdominal pain
- Altered mental state; coma (5%)
- Acetone breath; Kussmaul breathing; tachypnoea
- Weight loss
- Weakness; lethargy
Temperature often subnormal even with infection
List three symptoms or signs of mild-moderate dehydration
- Increased thirst
- Tiredness
- Dizziness/headache
- Oliguria
- Dry mucous membranes
- Sunken eyes
- Postural hypotension
- Reduced skin turgor
- Delayed capillary refill
List five signs of severe dehydration
- Weakness
- Confusion; coma
- Tachycardia with weak pulse
- Hypotension
- Anuria
How may DKA present on NEWS score?
- EWS >6
- Pulse >100 bpm or <60 bpm
- SBP <90 mmHg
- GCS <12 or abnormal AVPU
- SaO2 <92%
Request five investigations in suspected DKA?
- Urine dip: ketonuria (2+); glycosuria
- ABG/VBG: pH <7.0
- VBG: HCO3 <5mmol/L
- Capillary and serum blood glucose
- Blood ketones >6mmol/L or ketonuria
- U+E: K+ <3.5mmol/L
- ECG; MI screen
- CXR
- Serum amylase
- MSU; blood cultures
Outline the immediate management of DKA
- A-E assessment
- If severe: immediate senior review; consider HDU/ITU
- IV access and 0.9% sodium chloride infusion
- Fluid resus if SBP <90
- 1st litre (1h); subsequent 2L (4h); 2L (8h); 2L (12h)
-
Potassium replacement
- >5.5: nil
- 3.5-5.5: 20mmol/500mL
- <3.5: senior review
-
Fixed rate IV insulin (Actrapid) [0.1 units/kg/h] ± IM/SC STAT
- Hourly ketone and CBG monitoring
- Continue any long acting insulin
- Add 10% glucose if CBG <14mmol/L
When is DKA considered to be resolved?
What subsequent management should occur once resolved?
Resolved DKA
- Venous pH >7.3; and/or
- Blood ketones <0.6mmol/L
Subsequent management
- Review insulin infusion: target CBG 5-10mmol/L
- Encourage oral intake and switch to SC insulin
- Otherwise switch to VRII
- Refer to specialist diabetes team
What is Hyperosmolar hyperglycaemic state (HHS)?
T2DM emergency characterised by:
- Hyperglycaemia
- Hyperosmolarity
- Dehydration
- Without significant ketoacidosis
List five potential triggers for HHS
- Co-morbidities:
- MI; stroke/TIA; PE
- Infection
- Pancreatitis; GI bleed
- Cushing’s syndrome
- Drugs:
- Metformin
- Thiazide diuretics; dialysis
- B-blockers; CCBs
- Steroids; alcohol
- Poor control; non-compliance; consumption of glucose-rich fluids
List three presenting features of HHS
- Initial:
- Dehydration; polyuria; polydipsia
- Weakness
- Leg cramps
- Visual impairment
- Lethargy; confusion; coma (rare)
- Seizures
Outline the management of HHS
-
Rehydrate slowly with 0.9% saline over 48h
- avoids cerebral damage
- Replace K+ when urine output improves
- Insulin if glucose not falling by 5 mmol/L
-
Maintain glucose 10-15 mmol/L in first 24h
- avoid cerebral oedema (rapid reduction of osmolarity causes reversal of fluid shift)
- Prophylactic LMWH and TED stockings
When should lactic acidosis be suspected over DKA?
- Severe metabolic acidosis with large anion gap
- Usually without significant hyperglycaemia/ketosis
