Diabetic Emergencies

Question 1

What causes diabetic emergencies?

Answer 1

1. Absolute/relative insulin deficiency (as in T1DM > T2DM)

• Causes lipolysis + metabolism of FFAs
  => Which results in glycerol (which undergoes gluconeogenesis) + KETONES
  => Also results in formation of beta-hydroxybutyrate, acetoacetic acid, and acetone in the liver

2. Stress

• Stimulates insulin counter-regulatory hormones (e.g., glucagon, catecholamines, glucocorticoids, growth hormone)
  => Excess glucagon causes increase gluconeogenesis and decrease peripheral ketone utilization

Question 2

Why does DKA (diabetic ketoacidosis) rarely occur in T2DM?

What diabetic emergency may occur in T2DM instead?

Answer 2

T2DM still have residual insulin production, protected from excessive lipolysis and ketone production (usually no ketones)

In T2DM pt, Hyperglycemia Hyperosmolar State (HHS) may occur instead

Question 3

What are the S&S of DKA?

Answer 3

Vomiting, abdominal pain, shortness of breath, fruity breath

Question 4

What are the clinical presentation of DKA?

• BG
• pH
• Bicarbonate level
• Urine or blood acetoacetate
• Urine or blood Beta-hydroxybutyrate
• Effective serum osmolality (mmol/kg)
• Anion gap
• Alteration in sensorium

Answer 4

• BG >14mmol/L
• acidic pH <7
• Lower bicarbonate levels
• Urine or blood acetoacetate positive
• Urine or blood Beta-hydroxybutyrate higher
• Osmolality lower, variable
• Anion gap higher
• Usually still alert

Others:
- Fruity breath odor

Question 5

What are the clinical presentation of HHS?

• BG
• pH
• Bicarbonate level
• Urine or blood acetoacetate
• Urine or blood Beta-hydroxybutyrate
• Effective serum osmolality (mmol/kg)
• Anion gap
• Alteration in sensorium

Answer 5

• BG > 33mmol/L
• alkaline pH >7
• Higher bicarbonate levels
• Urine or blood acetoacetate negative/low
• Urine or blood Beta-hydroxybutyrate lower
• Osmolality higher (concentrated)
• Anion gap lower
• Stupor, coma

Others:
- Extremely dehydrated (therefore BG high)