Diabetes

Question 1

Define Diabetes:

Answer 1

Chronic systemic disorder in which the body’s ability to produce or respond to the hormone insulin is impaired. This results in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood (hyperglycaemia).

Question 2

Pathophysiology of diabetes

Answer 2

• In a healthy individual, blood glucose levels range between 4-8 mmol/l and are maintained via Beta and Alpha cells in the pancreatic islet of Langerhans.
• Beta cells secrete insulin when blood glucose levels increase.
• Insulin decreases blood glucose by facilitating the transfer of glucose into cell membranes via insulin receptors
• The insulin signals the cell to insert GLUT 4 transporters into the cell membrane to allow the entry of glucose into the cell.
• Insulin also slows down the conversion of glycogen into glucose, as well as slowing down the conversion of glucose from lactic/ amino acid to glycogen
• Alpha cells release glucagon when blood glucose levels decrease in order to increase blood glucose levels

Question 3

Type 1 Diabetes

Answer 3

An autoimmune disease which result in the destruction of Beta cells, leading to little or no insulin production

Question 4

Type 2 Diabetes

Answer 4

• Generally found in people over 40 and overweight
• Thought to be associated with the resistance to the action of insulin
• Cause generally unknown

Question 5

Secondary Diabetes

Answer 5

Destruction of islet cells following chronic pancreatitis or cystic fibrosis

Question 6

Gestation Diabetes

Answer 6

High blood glucose during pregnancy

Question 7

Chronic complications of diabetes

Answer 7

• Cardiovascular, peripheral vascular, eye, kidney and skin disease
• Peripheral and autonomic neuropathy

Question 8

Acute Complications of Diabetes: Diabetic Ketoacidosis (DKA)

Answer 8

• Most often in Type 1 – blood glucose above 17mmol/l
• A lack of insulin stimulates the breakdown of fat by gluconeogenesis producing ketones
• Ketones are acidic and leads to metabolic acidosis

Question 9

DKA Signs and Symptoms

Answer 9

• Polyuria and polydipsia
• Weight loss
• Lethargy
• Recurrent infections especially thrush
• Blurred vison
• Vomiting
• Abdominal pain
• Confusion
• Pear drop smelling breath
• Dehydration
• Kussmaul breathing

Question 10

DKA Treatment

Answer 10

Treatment as per JRCALC – systolic BP below 90 – administer sodium chloride 0.9% - transfer to A&E for further treatment

Question 11

Acute Complications of Diabetes: Hyperosmolar Hyperglycaemic State

Answer 11

• Type 2 diabetes – blood glucose above 30mmol/l
• Minimal insulin production allows for metabolism of fats so no ketones
• Often triggered by illness/ infection

Signs, symptoms and treatment are similar to that of DKA

Question 12

Acute Complications of Diabetes: Hypoglycaemia

Answer 12

• Blood glucose below 4mmol/l

- Can be caused by too much insulin, reduced food intake or too much exercise

Question 13

Hypoglycaemia Signs and Symptoms

Answer 13

• Sweating
• Trembling/ shaking
• Palpitations/pounding
• Hunger
• Headache
• Nausea
• Incoordination
• Confusion
• Speech difficulty – slurred speech
• Drowsiness
• Odd behaviour
• Aggression/ combative behaviour
• Fitting
• Unconsciousness

Question 14

Hypoglycaemia Treatment

Answer 14

Treatment as per JRCALC – stepwise approach from mild to severe – quick acting carbohydrates – 40% glucose gel – IM glucagon – IV glucose 10% - transfer to A&E

Question 15

Assessment for Hypo/Hyperglycaemia

Answer 15

DRA(c)BCD

Question 16

DANGER assessment for hypo/hyperglycaemia

Answer 16

• Assess for any potential dangers

* Manage any bleeds

Question 17

RESPONSE assessment for hypo/hyperglycaemia

Answer 17

AVPU - assess

Question 18

AIRWAY assessment for hypo/hyperglycaemia

Answer 18

• Clear?

- Correct if compromised

Question 19

C-SPINE assessment for hypo/hyperglycaemia

Answer 19

Is this a concern based on MOI?

Question 20

BREATHING assessment for hypo/hyperglycaemia

Answer 20

• Respiration rate?
• increased/ decreased respiration?
• ketones?
• Assist with ventilation if required

Question 21

CIRCULATION assessment for hypo/hyperglycaemia

Answer 21

• Heart rate?
• Palpable radial pulse?
• Capillary refill?
• Oxygen saturations?
• Skin tone- Flushed?
• Correct if necessary

Question 22

DISABILITY assessment for hypo/hyperglycaemia

Answer 22

• Temperature
• Blood glucose below 4mmol/l or above 17mmol/l
• Blood pressure
• PEARL
• Equal and bilateral air entry
• 12 ECG
• Alerted GCS?

Question 23

History for assessing hypo/hyperglycaemia

Answer 23

• When did this start?
• Known diabetic?
• Polyuria?
• Polydipsia?
• Recent weight loss?

Question 24

Treatment for HYPOglycaemia

Answer 24

Treat as per JRCALC:

Correct any ABC problems immediately

Question 25

Treatment for SEVERE HYPOglycaemia (e.g. patient is fitting/combative/unconscious/increased risk of aspiration or choking)

Answer 25

• Administer IV glucose 10% over 15 minutes (10g – max 30g)
• IM glucagon if IV is not possible (1mg – max 1 mg)
• Re-assess blood glucose every 10 minutes
• If blood glucoses remain below 4mmol/l continue IV glucose 10% until blood glucose is above 4mmol/l
• Pre alert and convey to nearest A&E

Question 26

Treatment for MILD to MODERATE HYPOglycaemia (e.g. Patient is conscious, orientated and able to swallow (mild), they may be confused, disoriented or combative (moderate) )

Answer 26

• Give quick acting carbohydrate e.g. 40% glucose gel (10-20g – max 20g)
• Reassess blood glucose every 15 mins
• If blood glucose is below 4mmol/L repeat steps
• If blood glucose is below 4mmol/L after 3 cycles (45minutes), consider IM Glucagon or IV glucose 10%
• If blood glucose is maintained above 4mmol/l and the patient is able to eat a normal meal (filled with carbohydrates) then there’s a possibility they can stay at home
• If blood glucose does not improve or patient deteriorates – pre alert and convey to nearest A&E

Question 27

Dosage of IV glucose for SEVERE HYPOglycaemia

Answer 27

10% over 15 minutes (10g – max 30g)

Question 28

Dosage of IM glucagon for SEVERE HYPOglycaemia

Answer 28

1mg – max 1 mg

Question 29

Dosage of quick-acting carbohydrate for MILD to MODERATE HYPOglycaemia

Answer 29

40% glucose gel (10-20g – max 20g)

Question 30

Treatment for HYPERglycaemia

Answer 30

As per JRCALC

• If BP is below 90 systolic administer sodium chloride 0.9%
• 12 lead ECG
• Oxygen therapy if saturations are below 94%
• Pre-alert and convey to nearest A&E