Diabetic Emergencies Flashcards
What is DKA and some precipitating factors?
DKA occurs when there is uncontrolled lipolysis (when in a state of severe hypoglycaemia), it results in an excess of free fatty acids which are converted to ketone bodies.
Common precipitating factors are:
- Infection
- Missed insulin doses/poor adherence
- Myocardial Infarction
What are the clinical features of DKA?
- Abdominal Pain,
- Polyuria, polydipsia and dehydration (due to increased urine output because of the hyperglycaemia),
- Kaussmal breathing
- Acetone smelling breath
- Ketoacidosis, Dehydration, Potassium inbalance
What is the diagnostic criteria for DKA?
- Glucose >11 or known diabetes mellitus
- pH < 7.3
- Bicarb < 15
- Ketones > 3 mmol or urine ketones ++
What is the management for DKS?
- Fluid replacement (Most DKA patients are around 5-8L depleted) with isotonic saline. Risk of cerebral oedema
- Insulin infusion should be started at a rate of 0.1 unit/kg/hour. Once Glucose is less than 14 mmol then an infusion of 10% dextrose should be started at 125mls/hr in addition to the saline.
- Correct electrolyte disturbances. Monitor potassium closely and may need to replace losses
When is DKA resloved?
- pH >7.3
- Blood ketones <0.6
- Bicarb > 15
Patient should be eating and drinking and started their regular insulin
What are some DKA complications?
- Gastric stenosis
- Thromboembolism
- Arrhythmias secondary to hyperkalaemia/hypokalaemia
- Iatrogenic complications due to fluid challenge (cerebral oedema, hypokalaemia, hypoglycaemia)
- ARDS
- AKI
What is hyperosmolar hyperglycaemic state and the pathophysiology?
HHS is caused by hyperglycaemia which results in osmotic diuresis, severe dehydrations and electrolyte disturbances.
Pathophysiology - Hyperglycaemia causes increased serum osmolality which causes osmotic diuresis and therefore severe volume depletion
What are some precipitating factors for HHS?
Precipitating factors:
Intercurrent illness,
Dementia
Sedative drugs
What are the clinical features of HHS?
- Signs of volume loss: Dehydration, Polyuria, Polydipsia
- Lethargy,
- Nausea and vomiting
- Altered level of consciousness,
- Focal neurological deficits
- Hyperviscosity
Will present over days
Explain the diagnosis of HHS
- Hypovolaemia
- Marked hyperglycaemia (> 30mmol)
- Raised osmolality (>320 mosmol/kg)
- WITHOUT hyperketonaemia or acidosis
What is the management of HHS?
- Fluid replacement, IV saline given at 0.5-1L per hour and monitor potassium levels
- DO NOT GIVE INSULIN - unless blood glucose stops falling whilst giving IV fluids
- VTE prophylaxis as patients are hyperviscous
What are some causes of hypoglyceamia?
- Insulinoma,
- Excess insulin
- Liver failure
- Addison’s Disease
- Alcohol (causes exaggerated insulin secretion)
What are the symptoms of hypoglycaemia?
If blood glucose is <3.3 then the symptoms are due to the release of glucagon and adrenaline
* Sweating
* Shaking,
* Hunger
* Anxiety
* Nausea
If blood glucose is <2.8 then symptoms are due to inadequate glucose supply to the brain
* Weakness,
* Vision changes
* Confusion
* Dizziness
Severe but uncommon features are:
* Convulsions
* Coma
What is the management of hypoglycaemia?
Management in the community:
* Give oral glucose (10-20g) or Dextrogel
Management in hospital:
* If awake then carbohydrate can be given,
* If unconscious thenIM glucagon can be give or 20% glucose solution IV
Why can ketogenesis occur in T1DM?
When there is insufficient glucose and glycogen stores are exhausted.
Liver converts fatty acids into ketones (which can be used as fuel). Excess ketone acids make the blood acidic
