Diabetes Flashcards
What are the types of DM
Type 1 = 99% Type 2 MODY CF RD Neonatal - transient or permanent
What is the aetiology of type 1
Genetics - usually FH
Trigger / environment - vit D?
Autoimmune destruction of beta cells
Can still have type 1 if obese but more likely type 2
How much destruction till symptomatic
90%
Possible role of detecting Ab before destroyed?
How does DM present
Polyuria Polydipsia New onset nocturnal enuresis = red flag Fatigue Weight loss \+- recurrent infection 25% present in DKA
How does DM present in <5
Heavier nappy Blurred vision Oral / vulval candidiasis Constipation Skin infection Behaviour change Irritable
How do you Dx DM
THINK, TEST, TELEPHONE TODAY
Test = finger prick capillary >11.1mol
What are other tests but don’t wait to get back to refer
Fasting BG >7
Venous BG increased on 2 occasions
OGTT - rare
Check AB - GAD +Ve if present = 100% type 1
Screen other autoimmune - TFT / coeliac - anti-TTG
FBC + U+E + formal lab glucose
HbA1c
How do you Rx new diagnosis of DM
Admit to hospital to start insulin and education
What education needs to be given
Life-long BG testing 4x daily Injection technique Insulin regimen Diet / carb counting High low sugars Sick day rules
What is sick day rule
Continue insulin when sick as liver produces glucose and insulin resistant when ill
What insulin regimen most popular
Basal bolus 1x LA 3x RA before meals Need to work out insulin to carb ratio by carb counting Correction doses if too high
What is new way to manage DM
Pump therapy
Programmed basal rate + bolus through the day
What is HbA1c
Glycoslated Hb
Shows control over 3 months as RBC 120 day life span
Aim <48 (NICE) or 58
What are symptoms with hypoglycaemia <4
Dizzy Weakness Blurred vision Sweating Increased HR Anxious Headache Hungry Irritable
How do you Rx hypoglycaemia
Fast acting sugar - tablets/ drink Recheck after 10 min Repeat if <4 If >10 give extra carb depending on weight Glucogel if unable to swallow
How do you treat severe hypo e.g. unconscious / seizure
IM glucagon to mobilise hepatic glucose 999 IV dextrose If low / still no return = IV steroid If normal BG but no return may be in post-octal state from seizure
What is hyperglycaemia
> 11
What is important in hyperglycaemia
Teach sick day rules
Test ketones
Avoid DKA
What are the symptoms of hyperglycaemia
Same as Dx Blurry Drowsy Dry skin Hungry
What causes DKA
Insulin omission leads to increased glucose, osmotic diuresis, increased FA and ketones
Poor compliance
Increased demand - illness / trauma
What are symptoms of DKA
N+V Abdo pain Sweet ketotic breath Dehydration Kausmaul resp - rapid + deep Drowsy Coma Shock - RR, HR, cold periphery but with no focal chest/ abdominal reason
What is the biochemical triad of DKA
Hyperglycaemia
Ketones > 1 in blood or urine
Acidosis - mild = 7.3, severe = 7.1, HCO3 <15
What is the algorithm for hyperglycaemia
If BG >17 check ketones
If not elevated - keep rechecking till BG settles
If up give extra dose of RA insulin, repeat after 4 hours and if not improving = 999
When do you call 999 instantly
SYmptomatic Vomiting 4 hours Heavy rapid breathing Abdominal pain Dehydration
What should you remember with DM
Never stop insulin
Extra doses insulin + regular carb even if BG high
How do you Dx DKA
Beside glucose + ketone
Capillary gas
Urine dip
What is Ddx for DKA
Sespsi
Cardiac
Respiratory infection / TB
How do you manage DKA
ABCDE Senior True coma rare so must exclude May also have sepsis Treat shock
How do you treat DKA
If shock / decreased GCS / coma or vomiting
- IV access +- 0.9% saline bolus (no K)
- Caution as risk of cerebral oedema so only if shock
IV insulin 1 hour after IV fluid
- 0.1 unit / kg / hrRA
- Switches of ketogenesis
Maintenance
- Over 48 hours
- Calculare maintenace plus dehydration dose
- K correction (KCL) + dextrose when BG falls <12
How do you monitor DKA
Monitor GCS as risk of cerebral oedema Look for signs of dehydration Blood gas + U+E 4 hourly BG + ketones hourly ECG Fluid inut Neuro obs 1 hour If headache / odd behaviour = REPOTT Infection screen - may have no fever
What are the symptoms of cerebral oedema
Headache = beware if this Vomit Irritable Decreased conscious Raised ICP Focal neuro Decreased HR Increased BP
What is the treatment of cerebral oedema
Senior Exclude hypo Mannitol 1g/kg IB Elevate head Restrict IV fluid CT PICU
What is important in the Hx
FH autoimmune / symptoms of DM when Dx
Drinking - amount, type of fluid, timing, nocturnal?
Micturition - how often, how much, nocturnal, wetting?
Assocatied Sx - weight loss, FTT, lethargy, N+V, abdominal pain, irritable, fever, vision, coordination
What is nocturnal enuresis
Involuntary discharge ofurine in the absence of acquired defects of nervous / urinary system
Primary - never continent
Secondary - had been content for 6 months
Majority reach continence by age 4
Abnormal if not by 5
What could be the underlying cause
Overactive bladder Constipated DM UTI Abuse
How do you treat / primary
Advise fluid / toilet
Reward system - for toiling before bed
Enuresis alarm <7
Desmopressiin >7 or failed alam (synthetic ADH)
What is the most common reason for polydipsia / uria
Habitual drinking Usually toddler Amount passed = amount drank Must exclude DM + URI Morning urine osmolarity may help
How do you treat habitual drinking
Offer only water
Limit milk to 500ml
Decreased flavoured drinks + sugar
What are most rarer reasons
Central diabetes inspidus
Nephrogenic DI
What is mild acidosis
7.3
Moderate acidosis
7.2
Severe acidosis
7.1
HCO3 <15
