ACT Endo,GI,Opth Flashcards
Description of hypoglycaemia
A blood sugar of < 4mmol/L
Aetiology of hypoglycaemia
EXogenous - Hypoglycaemics, Alcohol Pituitary Liver failure Addisons Insulinoma Non pancreatic neoplasms Sepsis
Presentation of hypoglycaemia
< 3.6 mol/L = Sympathetic overactivity
Sweating, pallor, tremor, anxiety, tachycardia
< 2.6 mol/L = Neuroglycopenia
Slurred speech, dizziness
Focal neurology (Stroke mimic)
Low GCS
< 1.5mol/L = Coma
Assessment and investigation of suspected hypoglycaemia
A to E approach, call for help if deteriorating
Finger-prick glucose
Bloods: Glucose in grey fluoride oxalate tube as BM not accurate when low
If not known to be DM: FBC, U&E, LFT, insulin, C-peptide (for insulinoma) BEFORE treatment
Management of hypoglycaemia
GCS 15 = 10g of glucose in quick release form
Followed by carbohydrate meal eg. bread
GCS < 15 + unable to get IV access = IM Glucagon 1mg
GCS < 15 = IV access + 100ml of 20% Glucose
Check CBG after 10mins, treat accordingly
Consider 1L 10% Glucose over 4-8hrs
Differentials for hypoglycaemia
Alcoholism - Consider Pabrinex
Stroke
Definition of Diabetic Ketoacidosis
BM > 11 mmol/L
Ketones 2+ on urine or >3mmol/L in serum
Acidosis – pH < 7.30
Reduced glucose absorption into cells causes hyperglycaemia, ketones are formed as a breakdown product of amnio acid metabolism
Aetiology of DKA
First presentation of DMT1 Infection - often without fever Non compliance with insulin regime Post Surgery MI, Pancreatitis, Chemotherapy, Antipsychotics
Investigation of suspected DKA
Urine dip - Ketones ++ Finger prick - Glucose + Ketones raised VBG - acidosis, reduced Bicarbonate FBC - raised WCC for infection U&Es - raised potassium BM - accurate value Amylase + Osmolarity if suspicious of HHS After stabilised investigate cause: ECG, Blood cultures, MSU, CXR
Management of DKA
A to E - request senior help
FIG PICK
Fluids - ?Bolus if <90mmHg systolic
then 1L over 1hr-2-2-4-4hrs
Insulin - 50 units Actrapid in 50ml normal saline
Infused at fixed rate 0.1 units/kg/hr
Glucose - Monitor hourly, consider Dextrose
Potassium - monitor, add K+ after 1st bag
Infection - investigate and treat
Chart fluid balance
Ketones - Monitor hourly
Differentials for DKA
Hyperosmolar Hyperglycaemic State (HHS)
- high blood sugar results in high osmolarity
- without significant ketoacidosis
- due to relative insulin deficiency
Description of an Upper GI bleed
Bleeding from any part of the bowl proximal to the large bowl delineated by the ligament of Treitz (suspensory muscle of duodenum)
Aetiology of upper GI bleeds
Peptic ulcer – NSAIDs, aspirin, H.pylori (35-50%)
Mallory-Weiss tear
Gastro-oesophageal varices (5-10%)
Oesophagitis (5-15%)
Oesophageal/gastric Ca
Coagulation disorders (thrombocytopenia, warfarin)
Assessment and investigation of upper GI bleeding
If unstable - A to E - senior help if stable Abdo exam + Digital rectal exam ECG - ? ischaemia Bloods: FBC, G&S, ?Crossmatch U&Es show increases urea, blood meal LFTs, Coagulation screen Osophago-gastoduodenoscopy (OGD) - Glasgow-Blachford for urgency - Campylobacter-like-organism (CLO) for H.pylori
Immediate management of unstable upper GI bleeding
A to E - senior help Protect airway - nurse on side 2 x large bore IV access Fluid resuscitation, Crossmatch 2-4 units Major haemorrhage protocol if no time Correct clotting Terlipressin 2mg slow IV Urgent Osophago-gastoduodenoscopy (OGD) - Glasgow-Blachford score high
