Diabetes: Acute Complications Flashcards
most common diabetic emergency
hypoglycaemia
def. of severe hypoglycaemia
need for external assistance
common causes of hypos
too much insulin
too little carbohydrate
missed/late meal
exercise
alcohol
sulfonyureas
sulfonylureas and problem in diabetes
they encourage beta cells to produce more insulin
but could cause too much insulin and cause a hypo
MoA of sulfonylureas
blocks ATP sensitive calcium channels (same action as ATP)
the cell depolarises
Ca2+ channels open
Ca2+ influx triggers insulin release
other causes of hypoglycaemia
decreased insulin requirements (e.g. weight loss)
liver disease
conditions associated with T1DM
- addision’s
- hypothyroidism
- coeliac
complications of DM
- autonomic neuropathy
- renal failure
- counterregulatory failure
- injection sites/lipohypertrophy
why can addison’s cause hypos
cortisol is important in counterregulation
but cortisol low in addisons
counterregulation mechanisms to insulin
pituitary secretes GH and ACTH
ACTH stimulates cortisol and adrenaline/epinephrine from adrenal gland
pancreas secretes glucagon
rise in what hormone causes the symptoms of hypos
adrenaline
released in response to low blood sugars to try to correct problem
below what blood glucose level is a patient likely to have reduced consciousness/coma
1.5mmol/l
symptoms of hypoglycaemia
shaky
fast heart beat
sweating
dizziness
hungry
headache
nausea
difficulty speaking
confusion
incoordination
irritable
blurry vision
odd behaviour (esp. children)
weakness
fatigue
elderly presentation of hypo
can have stroke like symptoms (e.g. hemiparesis)
what happens to counterregulatory mechanisms over time with diabetes
deficiencies in counterregulatory hormones increase over time
describe cycle of hypoglycaemia un/awareness
hypoglycaemia episode → impaired physiological responses to hypoglycaemia → reduced awareness of hypoglycaemia → increased vulnerability to further episodes → less likely to detect as early → more severe hypo
diagnosis of hypoglycaemia
2 of 3 of whipple’s triad
- typical symptoms
- biochemical confirmation (<4mmol/l)
- symptoms resolve with carbohydrate
but don’t delay treatment to wait for confirmation
management of hypos
if safe swallow - sweet drink or dextrose tablet
if not - IV 20% dextrose
if can’t get IV - intramuscular glucagon and sweet drink
follow up with slow release carbohydrates
what should be done if recovery is not rapid after management of hypo
consider other causes
driving consideration after hypo
full cognitive recovery can take 45 minutes so can’t drive
risk factors for attending hospital with hypo
elderly
live alone
comorbidity
sulfonylurea therapy
after care of hypo
inform diabetes team
discharge unless caused by sulfonylureas
tell them to monitor glucose closely for 72h
treat cause if possible
reduce insulin/sulfonylurea dose
what do you need to take when you’re driving as a diabetic
GLC meter
or
real time glucose monitoring
or
flash glucose monitoring
rescue carbohydrate (snack)
ID saying you have diabetes in case of accident
what do you need do before driving
check glc before any journey
long journey rules in diabetes
test every 2h and take regular snacks
what glc require action before driving
if <5mmol/l - take a snack
if 4mmol/l - do not drive, treat hypo and wait 45m
what should you do if you have a hypo while driving
stop vehicle as soon as safe
switch off engine
remove keys from ignition
get out of driver seat
what 45m after normal glc before driving
who has extra rules for driving in diabtes
group 2 licenses and taxi drivers depending on local authority
what must you inform the DVLA of
more than 1 severe hypo in last year whilst awake
if you or your carer think you are at high risk of developing a hypo
if you develop impaired awareness of hypos
suffer hypo while driving
hyperglycaemia in type 1 leads to
diabetic ketoacidosis
hyperglycaemia in type 2 leads to
hyperosmolar hyperglycaemic state
dka management
fluids - fast then slow
IV insulin
monitor K+
determine cause
give 10% glucose when blood glucose reaches 14 or less
what is common cause of DKA
infection
errors/omissions
initial presentation of T1DM
presentation of DKA
polyuria
polydipsia
hypovolaemia
abdo pain
nausea and vomiting
kussmaul breathing
ketotic breath
muscle cramps
evidence of cause (e.g. sepsis)
DKA managment after the event
swap to subcutaneous insulin once patient eating and drinking
ensure basal inulin is given an hour or more before IV insulin stops
biochem findings in HHS
marked hyperglycaemia
raised osmolality
mild/no ketoacidosis
biochem findings in HHS
marked hyperglycaemia (>30)
raised osmolality
mild/no ketoacidosis
severe dehydration and pre-renal failure
presentation of HHS
hypercoagubiliy
profound dehydration
confusion
comas
fits
gastroparesis
nausea
vomiting
haematemesis
HHS management
slower prolonged rehydration (slow reduction in Na+)
gentler glucose reduction (than DKA)
anticoagulation (prophylactic sc heparin)
seek cause
how is metformin secreted
through kidney
does metformin cause lactic acidosis
no
when does metformin accumulate
late renal disease
when should you stop metformin
if eGFR<30 or worsening quickly
during tissue hypoxia
- shock
- MI
- sepsis
- dehydration
- acute renal failure
for 3 days after iodine containing contrast
check U&Es before reinstating
2 days before general anaesthetic
reinstate once stable renal function
