diabetes emergencies Flashcards
definition of a hypo
<4
definition of a severe hypo
a hypo that requires assistance
how many severe hypo’s before driving licence revoked in a year
2
causes of hypoglycaemia
- excess insulin administration
- overdose of other antidiabetic medication eg SU’s
- not eating enough carbs
- alcohol excess
- physiological stressors
- rarely (insulinomas, addison’s disease)
symptoms of hypoglycaemia
- adrenergic symptoms due to adrenaline release
- sweating
- trembling
- tachycardia
- anxiety
- hunger
- pallor
- nausea
- vomiting
- neuroglycopaenic symptoms
- confusion
- tiredness
- irritable
- visual disturb
- arrhythmias
- seizure
hypo management if mild
abcde
- if mild/conscious then give 15g glucose surgary drink wait 10 mins and reassess, repeat 3x then call dr
- give long acting carb after
hypo management if severe and unconscious
- establish IV access 10% dextrose 150ml or 80ml
- glucagon 1mg IM
why dont you get ketones in 2dm
as some insulin prevents uncontrolled lipolysis as only need a very small mount
causes of DKA AND HHS 4I’s
insufficient insulin
infection
infarction
intercurrent illness
inx of hyperglycaemia
- capillary prick
- ketones
- urinalysis
- urea and electrolytes
- arterial blood gases
- fbc
- bp and hr
- ecg for potassium signs
- cxr for cause and blood cultures
ecg signs of hyperkalaemia
flattened p wave and prolonged QRS segment, tall peaked t weaves and sign wave, shortened qt interval
3 parameters for dka
hyperglycaemia >11
ketones >3
acidosis ph <7.3 or bicarb <15
how can dka cause mortality
- children by cerebral oedema
- adults by hypokalaemia, ards, comorbid
who gets dka 1 or 2
usually 1
precipitation of dka
- intercurrent illness as need to increase insulin
- eating disorder
- non-compliance
- infection
- infarction
what causes ketosis
- insulin deficiency exacerbated by elevated catecholamines and other stress hormones that cause unrestratined lipolysis
- lots of FFA for hepatic ketogenesis
2 types of ketones
3-hydroxybutyrate and acetoacetate
symptoms of dka
- dehydration (osmotic diuresis)
- electrolyte loss (na and k)
- polyuria
- weight loss
- weakness
- N&V
- leg cramps
- blurred vision
- abdo pain : amylase raise
- kussmaul breathing and smell of acetone
- hypotension
- hypothermia
why do infected patients with dka get pyrexia
vasodilation secondary to acidosis
inx dka
- venous blood
- urinalysis or blood for ketones
- ecg for hyperk
- blood cultures and cxr
- blood pressure hypovolaemia
- anion gap
dka is potassium raised or not raised
- in the blood potassium are raised as pH causes efflux from cells
- but potassium is intracellular cation so actually is low
what needs to be given with insulin
potassium as insulin also drives potassium out of cells
definition of severe dka
blood ketones>6 bicarb <5 pH <7 hypok already gcs <12 o2 <92% hr >100 or <60
what is the anion gap formula and usual range
(Na+K)-(Bic+Cl)
8-16
causes of a raised anion gap
KUSMAEL ketoacidosis uraemia salicyltaes methanol alcohol ethylene glycol lactate
management of DKA
think VIP
- volume- iv initially fast than slower to rehydrate 0.9% saline per hr, more rapid in shock
- insulin: 6 units actrapid, give dextrose if blood glucose drops
- potassium: when give insulin get potassium shift into.
- low molecular weight heparin due to hypercoaguable state
- avoid hypos so add glucose after an hr 10%
- ECG risk of arrthymias
what potassium level means insulin shouldn’t be started
<3.5
dka protocol 0-60 minutes
- confirm dx
- iv fluid sodium chloride
- insulin treatment soluble
- monitoring
dka protocol 60-6 hours
- give sodium chloride iv with potassium after checking K+
- as hyperkalaemia can occur if given too early
- add 10% glucose when <14
- continue insulin
- seek fluid balance chart
- prescribe low molecular weight heparin prophylactically due to risk of dvt
dka protocol 12-24 hours
if patient is not eating and drinking still due to ketoacidosis then lower insulin
additional management dka
-urinary catheterisation if anuric after 3 hours or incontinent
-insert nasogastric tube if persistent vomiting or gastroparesis
-insert central venous line if cardio system if compromised
measure arterial bg
-ecg monitor
-thrombophylaxis
definition of a severe dka
pH <7
bicarb <5
management if severe dka progressed to cerebral oedema and who is at risk
younger patients are at risk of cerebral oedema if too much fluid
-dexamethasone and mannitol
management after DKA
- continue with long acting throughout treatment
- give short acting insulin once eaten
- can stop IV insulin when eating normal
parameters of HHS
Hyperglycaemia >30
Hyperosmolar >320
Hypovolaemia secondary to osmotic diuresis
blood ketones <3
marked hyperglycaemia without any hyperketonaemia
cause of HHS
seen in 2dm due to relative deficiency of insulin rather than absolute 4I’s
speed of onset of HHS
slower than DKA over several days so metabolic disturbance more extreme
mortality HHS
HHS has a higher mortality rate than DKA due to prevalence of co-morbidities in 2dm
management of hhs
- fluids 0.9% sodium chloride given at a slower rate (1l over first hr), slower if cardiac failure
- Insulin 0.05 units/kg/ hr IV
- monitor potassium
- antibiotics
- prophylactic heparin
aim for reduction of osmolality of HHS at and fluid balance of
3-8 mmol kg per hr
2-3L positive fluid balance by 6 hours
why does iv fluid for HHS need to be given slower
HHS develops slower so sudden reversal of fluid status can cause seizures, cerebral oedema and cerebral pontine myelinolysis
symptoms of HHS
-insidious onset
-profound dehydration (9-10L deficit)
-hypercoaguability
-confusion,coma and fits
-gastroparesis, N&V
-polyuria, polydipsia
-weakness,cramps
-neuro symptoms: acute stroke/ focal weakness
-seizures
-n&v
-coma 10%
high mortality
signs of HHS
- dehydration: tachycardia, hypotension, decreased skin turgor
- general exam look for cause pneumonia, MI
- focal/ global neurological dysfunction
- acute abdo pain-paralytic ileus, gastroparesis
inx hhs
o Finger prick glucose
o Bloods-glucose, bicarb, u&e
o Culture
o ABG often acidosis
o Serum osmolality
o Urine: ketones, glucose dipstick, +/- MSU
o ECG if hyperk- flattened p waver, prolonged QRS segment, tall peaked T waves, and sign waves
o CXR
o May need CT/ MRI head if concern of cerebral oedema
complications of hhs
- embolic: ischaemia, infarction
- hypoKa, cardiac failure
- cerebral oedema
- foot ulcers
- multi-organ fail, ards
what can metformin cause
lactic acidosis
how is metformin excreted
kidney
when should metformin not be given
if eGFR <30 cr 130-150
- tissue hypoxia present
- iodine containing contrast mediuum
