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Endocrine > Diabetes Emergencies > Flashcards

Diabetes Emergencies Flashcards

1
Q

Diabetic emergencies (4)

A 
Diabetic ketoacidosis (DKA)
Hyperglycaemia Hyperosmolar Syndrome (HHS) 
Alcohol/ Starvation Ketoacidosis 
Lactate Acidosis
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2
Q

Diabetic Ketoacidosis

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, GH)

Can occur in T1DM and T2DM

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3
Q

DKA Pathophysiology

A 
Absolute insulin deficiency 
Hyperglycaemia 
Fat breakdown 
Ketones formed
Dehydration from hyperglycaemia 
Osmotic diuresis
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4
Q

DKA at risk patients

A

Mainly T1Dm

Acute illness (e.g. infection) –> stress hormones

Omission/ inadequate insulin/ pump failure

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5
Q

DKA Presentation onset

A

Acute (hours)

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6
Q

DKA diagnostic criteria

A

Blood glucose 11mmol/L or more
Venous pH <7.3 ot bicarb <15mmol/l
Blood ketones >3mmol/l
Urine Ketones 2+ or more

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7
Q

Mortality in DKA (causes of death)

A

Adults

  • Hypokalaemia
  • Aspiration pneumonia
  • ARDS
  • Co-morbidities

Children
-Cerebral oedema

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8
Q

Precipitants of DKA

A

Insulin deficiency
- poor compliance/ management

Increase insulin demand

  • Infections: pneumonia, UTI, cellulitis
  • Inflammation (pancreatitis, cholecystitis)
  • Intoxication
  • Infarction (acute MI, stroke)
  • Iatrogenic (steroids, surgery)
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9
Q

DKA typical symptoms and signs

A

Osmotic related

  • thirst and polyuria
  • dehydration

Ketone body related

  • flushed
  • vomiting
  • abdo pain and tenderness
  • Breathless: Kussmauls Respiration

Associated conditions

  • Underlying sepsis
  • Gastroenteritis
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10
Q

DKA Classical Biochem

A 
Glucose Raised (>11mol/L)
Blood ketones usually >5
Bicarb <10 in severe cases

Potassium

  • often raised to >5.5mmol/L
  • Beware low normal reading.

Creatinine
- often raised

Raised lactate is common

WWC

  • Median 25
  • Does NOT always equate to infection

Amylase often raised

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11
Q

DKA management principles

A

Manage in HDU following hospital protocol

Replace losses

  • Fluid (initially with 0.9% sodium chloride. Switch to dextrose when glucose falls to ~15)
  • Insulin
  • Potassium

Address risk

  • Monitor K+
  • Prescribe prophylactic LMWH
  • Source sepsis
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12
Q

DKA Treatment (7)

A

IV Fluid resuscitation

  1. 1000ml NaCl 0.9% in first hour
  2. 2000ml NaCl by end of 2nd hour
  3. 3000ml NaCl by end of 4th hour

Monitoring

  1. Blood for U&Es and bicarb level (2nd hr)
  2. Blood for U&Es and bicarb level (4th hr)
  3. IV potassium replacement

Insulin
7. ‘Usual’ subcutaneous basal insulin given daily

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13
Q

Blood Ketone Testing

A

Measures beta-hydroxy butyrate

meter range 0-8 mmol/L

<0.6mmol/L. is normal

Preferred ketone test

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14
Q

Urine ketone testing

A

Measure acetoacetate

Indicates levels of ketones

Ketonuria persists after clinical improvement due to mobilisation of ketones from fat tissue

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15
Q

HHS

A

hyperglycaemia hyperosmolar syndrome

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16
Q

HHS at risk patients

A

Occurs in people with T2DM who experience very high blood glucose levels (often >40mmol/L)

T2DM undiagnosed
Older adults
Acute illness
Illness that results in reduced fluid intake
Omission/ inadequate insulin
Drugs that raise glucose levels or cause dehydration

17
Q

HHS pathophysiology

A 
Relative insulin deficiency 
Precipitating illness
Hyperglycaemia 
Little fat breakdown/ ketones 
Dehydration from hyperglycaemia 
Osmotic diuresis
18
Q

HHS presentation onset

A

Sub-acute (can be days )

19
Q

HHS diagnostic criteria

A

Blood glucose 30mmol/l. or above

Urine ketones sometimes present
No/mild ketonaemia <3mmol/L

Osmolarity >320

Hypovolaemia

Bicarb. 15mmol/L or venous pH .7.3

20
Q

HHS typically features

A

Often presents in older patients or. young afro-carribeans

High refined carbohydrate pre-presentation

21
Q

HHS risk associations and complications

A 
CV disease
Sepsis 
Medication 
- steroids 
- thiazide diuretics
22
Q

HHS typical biochemistry

A

Higher glucose than in DKA
-typically >50mmol/L

Significant renal impairment

Sodium often high normal or raised

Less ketogenic/ acidotic than in DKA

Raised Osmolarity (>320) 
- Normal: 275-295
23
Q

HHS treatment

A

Normalise osmolarity gradually and safely

  • replace fluid and electrolyte. losses
  • normalise blood glucose

Treat. underlying cause

Assess severity of dehydration
- 0.9% saline for fluid replacement WITHOUT insulin

Monitor and chart blood glucose, osmolarity and sodium

Start low dose IV insulin ONLY if significant ketones (>1) or if Bg falling at slow rate

Identify underlying precipitants

24
Q

Alcoholic/ Starvation Ketoacidosis

A

History is important

Dehydration is common: often marked

25
Q

Alcoholic/ Starvation Ketoacidosis Biochem

A

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

Bicarb usually <15mmol/L

Venous pH <7.3 in severe cases

Glucose usually normal (may be low)

26
Q

Lactate

A

Lactate is the end product of anaerobic metabolism of glucose

Clearance requires hepatic uptake and aerobic conversion to. pyruvate then glucose

Normal lactate range: 0.6-1.2 mmol/L

Generally lactate lowest in fasted state

In severe exercise lactate may rise to 10mmol/L

27
Q

Lactate Acidosis Type A

A

Associated with tissue hyperaemia

  • Sepsis (endotoxic shock)
  • Haemorrhage
28
Q

Lactic Acidosis Type B

A

May occur in

  • liver disease
  • Leukaemic states
29
Q

MALA

A

Metformin associated lactic acidosis

30
Q

Lactic acidosis clinical features

A

Hyperventilation
mental confusion
stupor or coma if severe

31
Q

Lactic acidosis lab findings

A 
Reduced bicarb
Raised anion gap 
Glucose variable (often raised) 
Absence of ketonaemia 
Raised phophate
32
Q

Lactate acidosis treatment

A

treat underlying conditions

  • fluid
  • antibiotics

Withdraw offending medication

Endocrine (25 decks)

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