Acute care- Endo Flashcards
3 most common precipitating factors to DKA
Infection
Missed insulin doses
MI
4 symptoms of DKA
Abdominal pain
Polyuria
Polydipsia
N+V
3 signs of DKA
Kussmaul respiration (deep hyperventilation)
Acetone-smelling breath (‘pear drops’)
Reduced consciousness
Diagnostic criteria of DKA
Glucose >11 or known DM
pH <7.3
Bicarbonate <15
Blood Ketones >3 or Urine ketones ++
Initial investigations/ interventions in DKA
IV access (2 large bore cannula)
Blood / urinary KETONES
Capillary + plasma blood GLUCOSE
FBC, U&Es, VBG
Blood cultures
Urinalysis +/- MSU, Pregnancy test
ECG
Cardiac monitoring
Establish usual diabetic pharmacotherapy
Bedside Ix performed in suspected DKA?
ECG
Urinalysis +/- MSU
Urinary pregnancy test
Bloods performed in suspected DKA?
FBC ?infection
U&Es ?electrolyte imbalance
CRP
LFTs ?hepatic precipitant
Blood cultures ?infectious precipitant
Troponin ?MI
What imaging may be performed in DKA?
CXR: if low O2 sats
Describe the insulin delivery in DKA
FRIII 0.1 u/ kg/ h
Once blood glucose <14, start 10% Dextrose at 125 ml/h
Continue LONG acting insulin
Stop SHORT acting insulin
Describe fluid resus in DKA when SBP is <90mmHg on admission
- 500mL bolus 0.9% NaCl over 10-15 mins.
2.
If SBP remains <90: repeat + contact senior
If SBP >90: give 1L NaCl over 1h
Add K+ to next 1L bag (if K+ <5.5)
In which patients with DKA is a slower infusion of IV fluids indicated? Why?
Young adults (18-25) as greater risk of cerebral oedema
When is cardiac monitoring required in management of DKA?
If rate of potassium infusion is >20mmol/h
At what rate should potassium be infused in DKA?
K+ >5.5: None
K+ 3.5-5.5: 40mmol/h
K+ <3.5: senior review as additional K+ needs to be given
What should have been resolved within the first 24h?
Both ketonaemia + acidosis
If not requires review by senior endocrinologist
What defines resolution of DKA?
pH >7.3 +
Blood ketones <0.6 mmol/L +
Bicarbonate >15 mmol/L
What signs may indicate cerebral oedema during management of DKA?
Headache
Irritability
Visual disturbance
Focal neurology
When does cerebral oedema usually occur during management of DKA? What should be performed if there is suspicion?
4-12h following commencement of Tx
Can present at any time
CT head + senior review
Ix for phaeochromocytoma
24h urinary metanephrines
Phaeo Mx
Phenoxybenzamine (alpha blocker)
Propranolol
Surgery
Thyroid storm precipitants
Surgery
Trauma
Infection
Thyroid storm Sx
Fever
Tachycardia
Confusion
Agitation
N+V
HTN
Thyroid storm Mx
Paracetamol
IV Propranolol + Propylthouracil + Lugols iodine + Hydrocortisone
4 precipitants to Myxoedema coma
Hypothermia
Infection
CVA
Trauma
4 Sx of myxoedema coma
Confusion
Hypothermia
Bradycardia
Resp depression
Ix for myxoedema coma
HIGH TSH
Low T3 + T4
Mx of myxoedema coma
IV Levothyroxine
IV Hydrocortisone (until possibility of adrenal insufficiency r/o)
IV fluids
Correct electrolytes
HHS Sx
Dehydration, polydipsia, polyuria
Lethargy + reduced consciousness
N+V
Typical parameters in HHS
Hypovolaemia
Marker hyperglycaemia >30
High serum osmolarity
No significant hyperketonaemia
No significant acidosis
HHS Mx
IV sodium chloride 0.5-1L/h
VTE ppx
Insulin ONLY if blood glucose stops falling
What are the complications of giving insulin in HHS?
May provoke sudden + dramatic fluid shift leading to central pontine myelinolysis
