Diabetic Emergencies

Question 1

What are the two diabetic emergencies?

Answer 1

-Diabetic ketoacidosis (DKA)
-Hyperglycemic Hyperosmolar State (HHS)

Question 2

What is the basic underlying mechanism for the two diabetic emergencies?

Answer 2

-Reduction in the action of insulin
-Elevated counterregulatory hormones

Question 3

What type of diabetes does diabetic ketoacidosis typically occur in?

Answer 3

Type 1

Question 4

What symptoms are unique to DKA?

Answer 4

*Nausea/Vomiting
*Abdominal Pain

-Fruity breath

Question 5

What are the classifications for DKA?

Answer 5

-Acidic Blood pH: <7.4
-Decreased bicarb (18 or less)
-Anion > 10
**Ketones Present!

Question 6

What are the three parts of the DKA triad?

Answer 6

-Hyperketonemia
-Metabolic acidosis
-Hyperglycemia

Question 7

What is the initial treatment for DKA?

Answer 7

Administer 0.9% Sodium Chloride (Normal Saline) at 500-1000mL/hr for first 1-4 hours

*bolus

Question 8

After initial treatment of DKA, if patient has a normal/high sodium level, what should be done?

Answer 8

Change to 1/2 NS and decrease rate by 50%

Question 9

After initial treatment of DKA, if patient has a low sodium level, what should be done?

Answer 9

Continue normal saline and decrease rate by 50%

Question 10

What is the blood glucose goal for DKA patients?

Answer 10

200 mg/dL

Question 11

When a patient with DKA approaches the target blood glucose, how should we adjust their treatment?

Answer 11

Change to D5W and 0.45% NS at 150-250 mL/hr until DKA resolves

Question 12

What is the second step in DKA treatment after fluids?

Answer 12

Insulin

-IV continuous infusion is preferred

Question 13

What rate should we start IV insulin at in DKA patients?

Answer 13

0.1 units/kg/hour and can add a bolus of 0.1 units/kg

Question 14

When do we transition from SubQ to IV insulin?

Answer 14

Blood Glucose Level < 200 mg/dL

And at least two of these criteria:

-Anion gap closes (< or = 12)
-Bicarbonate level > or = 15
-Venous pH >7.3

Question 15

What is a contraindication to changing to SubQ insulin from IV?

Answer 15

If the patient cannot eat food by mouth

Question 16

What number signals that the anion gap has closed?

Answer 16

< 12 mEq/L

Question 17

When transitioning from IV to SubQ what overlap time should be used?

Answer 17

2-4 hours

Question 18

What is the anion gap equation?

Answer 18

Na - (Chloride + Bicarbonate)

*a gap occurs when > or = 12

Question 19

What does the presence of an anion gap indicate?

Answer 19

Metabolic acidosis

Question 20

What happens to potassium in DKA?

Answer 20

-Becomes extracellular
-Increased potassium levels

Question 21

At what potassium level do we not want to start fluids?

Answer 21

K < 3.3

Question 22

At what potassium level do we not have to provide any supplementation?

Answer 22

K > 5 mmol/L

Question 23

What happens to sodium in DKA?

Answer 23

Intracellular fluid moves to extracellular space which makes sodium appear low

*must correct for this

Question 24

What happens to phosphate during DKA?

Answer 24

Phosphate concentration decreases with insulin therapy

*WE DO NOT REPLETE PHOSPHATE

Question 25

At what pH do we replete bicarb?

Answer 25

<6.9

Question 26

What type of diabetes is typically associated with HHS?

Answer 26

Type 2

Question 27

What do we want to restore urine output to in HHS?

Answer 27

50 mL/hour or more

Question 28

What is the initial treatment for HHS?

Answer 28

0.45% or 0.9% Sodium Chloride (NS) at 500-1000 mL/hr for first 1-4 hours

Question 29

What is the goal blood sugar for HHS patients?

Answer 29

300 mg/dL

Question 30

When a patient with HHS reaches the target blood sugar, how should we adjust their treatment?

Answer 30

Change to D5W w/ 0.45% NS at 150-250 mL/hr until resolution of HHS

Question 31

What glucose level do we want to maintain before switching to SubQ insulin in a patient with HHS?

Answer 31

200-300 mg/dL