Acute care- Endo

Question 1

3 most common precipitating factors to DKA

Answer 1

Infection
Missed insulin doses
MI

Question 2

4 symptoms of DKA

Answer 2

Abdominal pain
Polyuria
Polydipsia
N+V

Question 3

3 signs of DKA

Answer 3

Kussmaul respiration (deep hyperventilation)
Acetone-smelling breath (‘pear drops’)
Reduced consciousness

Question 4

Diagnostic criteria of DKA

Answer 4

Glucose >11 or known DM
pH <7.3
Bicarbonate <15
Blood Ketones >3 or Urine ketones ++

Question 5

Initial investigations/ interventions in DKA

Answer 5

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

Question 6

Bedside Ix performed in suspected DKA?

Answer 6

ECG
Urinalysis +/- MSU
Urinary pregnancy test

Question 7

Bloods performed in suspected DKA?

Answer 7

FBC ?infection
U&Es ?electrolyte imbalance
CRP
LFTs ?hepatic precipitant
Blood cultures ?infectious precipitant
Troponin ?MI

Question 8

What imaging may be performed in DKA?

Answer 8

CXR: if low O2 sats

Question 9

Describe the insulin delivery in DKA

Answer 9

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

Question 10

Describe fluid resus in DKA when SBP is <90mmHg on admission

Answer 10

1. 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)

Question 11

In which patients with DKA is a slower infusion of IV fluids indicated? Why?

Answer 11

Young adults (18-25) as greater risk of cerebral oedema

Question 12

When is cardiac monitoring required in management of DKA?

Answer 12

If rate of potassium infusion is >20mmol/h

Question 13

At what rate should potassium be infused in DKA?

Answer 13

K+ >5.5: None
K+ 3.5-5.5: 40mmol/h
K+ <3.5: senior review as additional K+ needs to be given

Question 14

What should have been resolved within the first 24h?

Answer 14

Both ketonaemia + acidosis
If not requires review by senior endocrinologist

Question 15

What defines resolution of DKA?

Answer 15

pH >7.3 +
Blood ketones <0.6 mmol/L +
Bicarbonate >15 mmol/L

Question 16

What signs may indicate cerebral oedema during management of DKA?

Answer 16

Headache
Irritability
Visual disturbance
Focal neurology

Question 17

When does cerebral oedema usually occur during management of DKA? What should be performed if there is suspicion?

Answer 17

4-12h following commencement of Tx
Can present at any time

CT head + senior review

Question 18

Ix for phaeochromocytoma

Answer 18

24h urinary metanephrines

Question 19

Phaeo Mx

Answer 19

Phenoxybenzamine (alpha blocker)
Propranolol
Surgery

Question 20

Thyroid storm precipitants

Answer 20

Surgery
Trauma
Infection

Question 21

Thyroid storm Sx

Answer 21

Fever
Tachycardia
Confusion
Agitation
N+V
HTN

Question 22

Thyroid storm Mx

Answer 22

Paracetamol
IV Propranolol + Propylthouracil + Lugols iodine + Hydrocortisone

Question 23

4 precipitants to Myxoedema coma

Answer 23

Hypothermia
Infection
CVA
Trauma

Question 24

4 Sx of myxoedema coma

Answer 24

Confusion
Hypothermia
Bradycardia
Resp depression

Question 25

Ix for myxoedema coma

Answer 25

HIGH TSH
Low T3 + T4

Question 26

Mx of myxoedema coma

Answer 26

IV Levothyroxine
IV Hydrocortisone (until possibility of adrenal insufficiency r/o)
IV fluids
Correct electrolytes

Question 27

HHS Sx

Answer 27

Dehydration, polydipsia, polyuria
Lethargy + reduced consciousness
N+V

Question 28

Typical parameters in HHS

Answer 28

Hypovolaemia
Marker hyperglycaemia >30
High serum osmolarity

No significant hyperketonaemia
No significant acidosis

Question 29

HHS Mx

Answer 29

IV sodium chloride 0.5-1L/h
VTE ppx

Insulin ONLY if blood glucose stops falling

Question 30

What are the complications of giving insulin in HHS?

Answer 30

May provoke sudden + dramatic fluid shift leading to central pontine myelinolysis