diabetes emergencies

Question 1

what is diabetes ketoacidosis?

Answer 1

a disordered metabolic state that usually occurs in the context of an absolute or relative insulin deficiency accompanied by an increase in the counter-regulatory hormones i.e. glucagon, adrenaline, cortisol and growth hormone.

Question 2

true or false, DKA only occurs in patients with T1?

Answer 2

FALSE
can occur in both

Question 3

what are the biochemistry thresholds needed for DKA diagnosis?

Answer 3

Ketonaemia > 3mmol /L, or significant ketonuria (>2+ on standard urine stick)

Blood glucose > 11.0 mmol /L or known DM (NB euglycaemic DKA).

Bicarbonate < 15 mmol /L or venous pH < 7.3

Question 4

what is the mortality rate for DKA in developed countries?

Answer 4

2-5%

Question 5

what are common DKA causes of death in adults?

Answer 5

Hypokalaemia, Aspiration Pneumonia, ARDS,
Co-morbidities

Question 6

what are common DKA causes of death in Children?

Answer 6

Cerebral oedema

Question 7

what are the 2 precipitants of DKA?

Answer 7

insulin deficiency
increased insulin demand

Question 8

what are the osmotic related DKA symptoms?

Answer 8

Thirst and polyuria
Dehydration

Question 9

what are the ketone body related DKA symptoms?

Answer 9

Flushed
Vomiting
Abdominal pain and tenderness
Breathless – Kussmaul’s respiration
NB not all individuals can smell ketones on breath

Question 10

what are the associated conditions with DKA?

Answer 10

underlying sepsis
gastroenteritis

Question 11

are amylase, creatinine and lactate raised in DKA?

Answer 11

yes

Question 12

what are the fluid losses in DKA?

Answer 12

Fluid: variable but can be up to 12L [30%TBW]
Sodium: ~500mmol
Potassium: 350 to 700 mmol [10 to 20%]
Phosphate: 50 to 100mmol

Question 13

what are the risks in DKA?

Answer 13

Aspiration Is he semi-conscious?
Septic?
Is Potassium a concern [low normal]
Is there a thrombo-embolic risk?

Question 14

what is the management of someone presenting with DKA?

Answer 14

Manage in HDU following hospital protocol
Replace losses
Fluid
Initially with 0.9% sodium chloride
Glucose falls to about 15, switch to dextrose
Insulin
Potassium
Phosphate [rarely] and Bicarbonate [almost never] replaced
Address risks
? is a naso-gastric tube required?
Monitor K+
Prescribe prophylactic LMWH
Source sepsis: CXR, Blood Culture, MSSU +/- viral titres

Question 15

how do we monitor ketones?

Answer 15

blood ketone testing
unrine ketone testing (indicates levels 2-4 hours previous)

Question 16

what are the biochemical markers in HHS (hyperglycaemic hyperosmolar syndrome)?

Answer 16

Hypovolaemia – usually marked

Marked hyperglycaemia > 30mmol/L

No/mild ketonaemia <3 mmol/L

Bicarbonate > 15 mmol /L or venous pH > 7.3

Osmolality >320 mosmol/kg

Question 17

what are the typical features of HHS?

Answer 17

Diabetes may be known at presentation – often not

Often presents in Older patients. Young Afro-Caribbean

High refined CHO intake pre-presentation

Risk association and complications
Cardiovascular disease [MI and/or Stroke]
Sepsis
Medication: steroids/thiazide diuretics.

Question 18

which has a higher blood glucose reading-DKA or HHS?

Answer 18

HHS

Question 19

true or false, HHS has no affect on Renal function?

Answer 19

false
significant renal impairment

Question 20

is HHS less ketogenic than DKA?

Answer 20

yes

Question 21

are patients older or younger in DKA compared to HHS?

Answer 21

younger

Question 22

is HHS more common in T1 or T2?

Answer 22

T2

Question 23

what is the mortality rate of HHS?

Answer 23

10-50%

Question 24

is alocohol associated keto acidosis a medical emergency?

Answer 24

yes