Diabetic Emergencies Flashcards by Bel Luscombe

What blood glucose level causes autonomic and neuroglycopenic symptoms occur

Autonomic - 3.6
Neuroglycopenic - 2.7

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False hypoglycaemia

Pts w consistently high glucose experience hypo symptoms at higher level than someone with good glycaemic control

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Causes of hypoglycaemia in diabetics

Carbohydrate - insulin/sulfonylurea therapy
Exercise
Alcohol
Vomiting
Breastfeeding
Other medical problems

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Medical problems that can cause hypoglycaemia in diabetics

Liver disease
Renal impairment
Hypoadrenalism
Hypothyroidism
Hypopituitarism
Insulinoma

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Why is insulin dose often decreased in diabetics with progressive renal impairment

Kidneys not clearing insulin so more insulin available - can cause hypo

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Autonomic symtoms of hypoglycaemia

Sweating
Shaking/tremor
Anxiety
Palpitations
Hunger
Nausea

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Neuroglycopenic symptoms of hypoglycaemia

Confusion
Slurred speech
Visual disturbances
Drowsiness
Aggression

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Hypoglycaemia unawareness

Loss of early warning signs of hypo
Often skip past autonomic signs straight to neuro signs

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Causes of hypoglycaemia unawareness

Incr diabetes duration
Very tight glycaemic control
Autonomic neuropathy

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How can hypoglycaemia unawareness be reversed

Hypo holiday

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Hypo holiday

Strict hypo avoidance by relaxing glycaemic control using insulin analogies of an insulin pump to reverse hypo unawareness

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Mild moderate and severe hypoglycaemia treatment

Mild - sugary drink / 5-7 glucose tablets / 3-4 tsp sugar in water
Moderate - 1-2 tubes glycogel bucally / jam honey treacle into cheek / IM glucagon
Severe - recovery position + 0.5-1mg IM glucagon / 75ml 20% IV glucose over 15mins / 150ml 10% glucose over 15 mins

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How to tell between mild moderate and severe hypoglycaemia

Mild - conscious and Lucid
Mod - conscious but cannot self administer
Severe - unconscious

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Risk of administering 50mls 50% IV glucose for severe diabetic hypo

Extravasion can cause chemical burns

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What must be given post diabetic hypo once glucose 4+

Longer acting carb

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When could the driving licence of a diabetic pt be revoked

Severe hypo requiring third party assisstance

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Signs of nocturnal hypo in diabetics

Waking with Rebound hyperglycaemia

Headache/hangover feeling

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Nocturnal hypo diagnosis and treatment

Glucose test during night or Continuous Glouces monitoring sensor
Analogue insulins, pre bed snack, change insulin time, insulin pump

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DKA

State of absolute or relative insulin deficiency resulting in hyperglycaemia and an accumulation of ketoacidosis in the blood w subsequent metabolic acidosis

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What blood glucose, pH, bicarbonate, serum ketones and urine ketones are usually seen in DKA

Glucose 14+
pH <7?3
Bicarbonate <15
Plasma ketones ~ >3
Urine ketones ~ >2\3

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Which 2 substances are unbalanced in DKA pathogenesis

Excess Catecholamines
Insulin deficiency

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How does catecholamine excess contribute to DKA

Promote triglyceride breakdown
Stim Gluconeogenesis

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Which ketones accumulate in the body in DKA

3 OH butyric acid
Acetoacetic acid

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What causes ketosis in DKA

FFA metabolism due to insulin deficiency

What terminates DKA instantly

Insulin

DKA clinical features

Abdo pain Vomiting Kussmauls respiration Ketones on breath Drowsiness Confusion Dehydration Tachycardia

Causes of DKA

Insulin omission Infection Pregnancy MI Alcohol/drugs Unknown

DKA diagnosis

VBG showing acidoses CBG Often raised urea and creatinine Elevated urine/plasma ketones

What types of ketosis may present with blood glucose below 14

Euglycaemic ketosis Alcoholic ketosis

Investigations after DKA

Pregnancy test ECG CXR MSU/ blood cultures Biochemical profile Lab glucose FBC HbA1c

What test results indicate greater DKA severity

Blood ketones 6+ Bicarbonate <5 pH <7.1 K+ <3.5 GCS <12 O2 says <92% Sys BP <90 Pulse <60 / >100

Potential DKA supportive management and monitoring

Level 2 bed Cardiac monitor NG tube Central venous pressure line Oxygen Urinary catheter Prophylactic LMW heparin IV antibiotic Monitoring of consciousness BP pulse temp glucose urine output K+ acidosis

Fluid therapy regimen for DKA

0.9% NaCl 1L stat 1L in 1hr 1L + 20mmpl KCl over 2 hrs 1L + KCl over 4 hrs 1L + KCl over 4 hrs

Why is K+ not given in 1st 2L of IV fluid administered to DKA pts

Given too rapidly

When should IV glucose be given in DKA treatment

125ml/hr 5/10% glucose When CBG <12 Incr infusion rate of glucose <6

Components for DKA treatment

Insulin 0.9% NaCl fluid Potassium 5/10% glucose

Why is insulin administration delayed in DKA pts w K+ <3.5

Insulin will further decr k+

How should insulin be given in DKA treatment

Continue long acting insulin on admission Start insulin infusion of 50u actrapid made up to 50ml in 0.9% NaCl by IV syringe pump Fixed rate insulin infusion 0.1u/kg

Bicarbonate and glucose changes aimed for during insulin therapy for DKA

Bicarbonate 3mmol/hr incr Glucose 3mmol/hr incr Incr insulin by 1u/hr if not achieved

Common3st cause of death from DKA in children

Cerebral oedema

Cerebral oedema treatment

Dexamethasone or mannitol

When does DKA pt return to normal sc insulin

Once eating and drinking reliably

Why are DKA pts often nauseous after DKA has subsided

Ketones not fully cleared

Is HHS more common in T1 or T2D

T2D

Glucose and osmolality levels normally seen in HHS

Glucose 40+ Osmolality 340+

Is HHS pt often hypernatraemic or hyponatremic

Hyper

Is ketonuria a component of HHS

Sometimes More likely if not eating due to starvation ketosis

What type of acidosis can occur in HHS

Lactic acidosis NOT ketoacidosis

Components of HHS

Hyperglycaemia High osmolality Severe dehydration Possibly hypernatremic, lactic acidosis, ketonuria

HHS treatment

IV Fluid IV insulin ~1u/hr Possible LMW heparin to decr thrombosis Possible central venous pressure monitoring

Is insulin dose higher in DKA or HHS treatment

DKA

Major risk of rapid glucose shift in HHS

Central pontine myelinolysis

Difference between DKA and HHS treatment

DKA - higher dose insulin given immediately HHS - much lower dose and not given for 1st 12 hrs

Which electrolyte often declines rapidly in HHS

K+

Max rate of glucose correction in HHS treatment

2mmol/L/hr

Diabetic sick day rules

Drink fluids Drink sugary fluids if unable to eat Monitor glucose more regularly Never stop tablets/insulin Insulin dose may need to be incr due to stress on body Pts on oral agents may need transferring to insulin Attend hospital if unable to keep fluids down

What should a diabetic pt do if they are unable to eat or drink

Unable to eat - sugary drinks Unable to drink - hospital

3 most life saving measures in diabetic emergencies

Fluid balance Insulin Potassium supplementation