Diabetes Emergencies Flashcards
How can diabetic ketoacidosis be defined?
A disordered metabolic state
Usually occurs in absolute or relative insulin deficiency as well as an increase in counter-regulatory “stress” hormones (glucagon, adrenaline, cortisol and growth hormone)
Ketoacidosis occurs as a result of lipolysis whilst stress hormones induce hyperglycaemia
How can DKA be biochemically diagnosed?
- >3mmol/l ketonaemia (>2++ of urine dipstick)
- >11.0 blood glucose
- <15mmol/l bicarbonate (or venous pH <7.3)
DKA is usually caused by which 4 main factors?
- Infection
- Non-adherence with treatment
- Newly diagnosed diabetes
- Alcohol and illicit drug use
5.
What are the key signs and symptoms of DKA?
- Thirst and polyuria
- Dehydration
- Flushed
- Vomiting
- Abdominal pain and weakness
- Breathless - Kussmaul’s breathing
- Ketones on breath
What are the two main associated conditions with DKA?
- Underlying sepsis
- Gastroenteritis
What is the range of blood glucose levels someone with DKA can present at?
10 - 100mmol/l
(usually it is around 40 mmol/l)
Above which level is potassium usually at in DKA presentation?
>5.5mmol/l
Why is it a worry if potassium levels are low upon presentation?
This can cause CV issues and death
What is the normal range of blood potassum levels?
3.5-5mmol/l
Below which blood potassium level is it considered dangerous?
<3.5mmol/l is considered hypokalaemia
2.5 - 3.0mmol/l is moderate hypokalaemia
<2.5mmol/l is severe hypokalaemia and is the most severe
How are the following affected in a typical DKA presentation:
a) Creatinine
b) Sodium
c) Lactate
a) Raised (poor kidney function)
b) Reduced
c) Raised (contributes mildly to acidosis)
Ketones will be above which level in the blood during DKA?
>5mmol/l
Which ketone is measured
a) In the blood
b) In the urine?
a) Beta-hydroxybutarate
b) Acetoacetate
In most severe cases of DKA, at which level is bicarbonate?
< 10mmol/l
(<15mmol/l is diagnostic)
Amylase is often raised in DKA, what may this indicate?
Pancreatitis
WCC in severe DKA is at around 25/nL, what may this infer?
- Infection
- Severity of DKA
What is the normal range of amylase in the blood?
Usually < 100 U/L
This varies drastically
Some ethnicities can have normal amylase levels at 180 U/L
Amylase levels around 900 U/L are almost diagnostic of pancreatitis
Less remarkably raised amylase levels are not so severely raised
What are the biggest risks of death for adults with DKA?
- ARDS
- Aspiration pneumonia (due to acute gastric dilatation)
- Hypokalaemia
What is the biggest risk in children with DKA?
Cerebral oedema
How is DKA treated?
- Fluid is given (0.9% NaCl)
- Insulin
- Potassium
- LMWH
Very rarely are phosphates and bicarbonate given as these correct themselves, but it is not wrong to correct them
Normal ketone levels are below which value?
<0.6 mmol/l
What is HHS?
Hypergylcaemic hyperosmolar syndrome
Which complication has a higher mortality?
DKA or HHS?
HHS
Which people are particularly at risk of HHS?
- Older people
- Younger people of non-caucasian background
3.
In a typical case of HHS, the patient either _______ know they have diabetes or they __________ _______ _______
In a typical case of HHS, the patient either doesn’t know they have diabetes or they control diet only
How can HHS be brought on?
- High refined sugar intake
- New diagnosis
- Infection
- Diuretic or steroid use
What are the main associated risks for HHS?
- Cardiovascular event (stroke or MI)
- Sepsis
- Medications (glucocorticoids and thiazide diuretics)
Blood glucose levels in HHS are generally _________ than in DKA
Blood glucose levels in HHS are generally higher than in DKA
How is osmolarity calculated?
2 x [Na+K] + urea + glucose
What is the normal range for osmolarity?
285 - 295 mmol/kg
Osmolarity levels in HHS acn exceed what?
400 mmol/kg
How do ketone and aidotic levels compare in HHS to DKA
They are both lower
Generally there is significant renal impairment with a typical case of HHS
True or false?
True
HHS involves a _____volaemic state
HHS involves a hypovolaemic state
DKA is generally associated with type ____ diabetes and HHS is associated with type ____ diabetes
DKA is generally associated with type 1 diabetes and HHS is associated with type 2 diabetes
How is HHS treated?
- Fluids (very careful not to overload)
- Insulin (more slowly than DKA as patient is more sensitive) - may not be required at all
- Sodium (increase very slowly and avoid rapid fluctuations)
- LMWH
- Oral antihyperglycaemic medication (for T2DM e.g. metformin)
- Diet
Lactate is removed in which way?
- Hepatic uptake
- Aerobic conversion to pyruvate and then to glucose
What is the normal range for lactate in the blood?
0.6 - 1.2 mmol/l
What is the formula to calculate the anion gap?
[Na+ + K+] - [HCO3- + Cl-]
What is the normal range for the anion gap?
10 - 18 mmol/l
What makes up the physiologically difference which causes the normal anion gap?
-ve Charged proteins, sulphate, phosphate and some organic acids
Type A lactic acidosis is associated with what?
Tissue hypoxaemia
What may be the causes of type A lactic acidosis?
- Infarcted tissue (e.g. ischaemic bowel)
- Cardiogenic shock
- Hypovolaemic shock (sepsis (endotoxic shock), haemorrhage)
In which instances may type B lactic acidosis occur?
- Liver disease
- Leukaemic states
- Diabetes
- Inherited metabolic conditions
What are the clinical features of lactic acidosis?
- Hyperventilation
- Mental confusion
- Stupor or coma if severe
What are the classical lab findings for type B lactic acidosis?
- Reduced bicarbonate
- Raised anion gap
- Glucose variable – Often raised
- Absence of ketonaemia
- Raised phosphate
What is the treatment for lactic acidosis?
- Fluids
- Antibiotics
- Withdraw causative drugs
- Treat underlying cause
In lactic acidosis, serum osmolarity is ________
In lactic acidosis, serum osmolarity is normal
What are blood glucose levels like in alcohol induced ketoacidosis?
Normal-high
What are the target and accepted blood glucose ranges for diabetic inpatients?
- Target level for glucose for hospital inpatients is 6-10mmol/L
- 4-12mmol/L is accepted
What is foot CPR?
- Check
- Protect
- Refer
