diabetic emergencies Flashcards
what is diabetic ketoacidosis
Diabetic ketoacidosis (DKA) is 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
biochemical diagnosis of ketoacidosis
- ketonaemia > 3mmol/L
- blood glucose > 11mmol/L
- bicarbonate < 15 mmol/L
reasons for increased insulin demand
- infections
- inflammatory
- intoxication
- infarction
- iatrogenic
5 I’s
osmotic symptoms of DKA
- thirst
- polyuria
ketone related symptoms of DKA
- flushed
- vomiting
- abdo pain and tenderness
- breathless
- ketones in breath
conditions associated with DKA
- underlying sepsis
- gastroenteritis
blood ketone level at ketosis
above 5
bicarbonate in severe cases of ketosis
<10
potassium in ketosis
above 5.5mmol/L
creatinine in DKA
raised
amylase in DKA
raised
sodium in DKA
low
management of DKA
Replace losses (FIPP) -Fluid, Initially with 0.9% sodium chloride, Glucose falls to about 15, switch to dextrose -Insulin -Potassium -Phosphate [rarely] Address risks -? is a naso-gastric tube required? -Monitor K+ -Prescribe prophylactic LMWH -Source sepsis: CXR, Blood Culture, MSSU +/- viral titres, etc.
IV fluid resuscitation treatment
- 1000mL NaCl 0.9% in first hour
- 2000mL NaCl by end of hour 2
- 3000mL NaCl by end of hour 4
what needs to be monitored in DKA
- blood for U&E’s and bicarbonate level hour 2
- blood for U&E’s and bicarbonate level 4
- IV potassium replacement
how are ketones monitored
- blood ketone monitoring
- urine ketone monitoring
what does HHS stand for
hyperglycaemic hyperosmolar syndrome
what is HHS
Hyperosmolar hyperglycemic state is a metabolic complication of diabetes mellitus characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness.
biochemical diagnosis of HHS
- 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
who usually gets HHS
older patients
young afro-carribean
what type of diabetes is HHS usually seen in
two
what type of diabetes is DKA usually seen in
one
what is the precipitant for HHS
new diagnosis infection
treatment for HHS
- use 0.9% saline for fluid replacement
- start low dose IV insulin only if significant ketones or if BG falling at a slow rate
- prophylactic fragmin
- identify underlying precipitants
- measure plasma osmality
- assess severity of dehydration
cause of HHS
- diuretics or steroids
- fizzy drinks
treatment for alcohol induced keto-acidosis
- IV anti-emetics
- IV Pabrinex
- IV fluids
Am Pretty Fucked
-insulin may be required on occasion
alcohol/starvation ketoacidosis biochemical diagnosis
- dehydration
- ketonaemia > 3mmol/L or significatn ketonuria
- bicarbonate < 15mmol/L
- venous pH < 7.3
- glucose normal
same but normal glucose
indications for hospital admission of type 1 diabetes
- unable to tolerate oral fluids
- persistant vomiting
- persistent hyperglycaemia
- positive/increasing level of ketones
- abdo pain
- breathlessness
what is normal lactate range
0.6 to 1.2 mmol/L
what is type A lactic acidosis
associated with tissue hypoxaemia
- sepsis
- haemorrhage
type B lactic acidosis
- liver disease
- leukaemic states
- diabetes
clinical features of lactic acidosis
- hyperventilation
- mental confusion
- stupor or coma if severe
lab findings of lactic acidosis
- reduced bicarbonate
- absence of ketonaemia
- raised anion gap
- raised phosphate
treatment for lactic acidosis
- fluids
- antibiotics
