Diabetic Emergencies Flashcards
What are the 3 diabetic emergencies?
Hypoglycaemia
Diabetic Ketoacidosis (DKA)
Hyperosmolar Hyperglycaemic State (HHS)
What is the normal function of insulin?
Anabolic hormone
Promotes cellular uptake of glucose from the blood
Stimulates liver to do Glycogenesis
Inhibits lipolysis
What is the function of glucagon?
Catabolic hormone.
Stimulates glycogenolysis in the liver
Stimulates Gluconeogenesis in the liver (from fats and proteins)
When are ketones produced in the body?
When insufficient glucose levels and glycogen stores are depleted, fatty acids converted to ketone bodies
Or
Insulin deficieny
What is the pathophysiology of. Diabetic ketoacidosis?
Insufficient insulin levels leads to failure of regualtion of Lipolysis
Excess lipolysis produces lots of ketone bodies which are acidic
Which organs attempt to counteract the acidity that is occurring in the development of diabetic ketoacidosis?
How?
Kidneys
Increase bicarbonate production (compensates until too many ketones then becomes acidic)
What are some precipitating factors that can lead to DKA (Diabetic Ketoacidosis)?
-Initial presentation of a Type 1 diabetic
-Insulin non compliance
-illness
-infections
-stress
-hypovolaemia
What are the symptoms of diabetic ketoacidosis?
Polyuria
Polydipsia
Weight loss
Dehydration
Fruity acetonic breath
Nausea + Vomiting
Altered consciousness
Hypotension
Palpitations
What are the 3 main signs of diabetic ketoacidosis?
Ketoacidosis
Dehydration
Potassium imbalance
Why do you get ketoacidosis with DKA?
Insulin deficieny leads to inadequate inhibition of lipolysis so lots of ketones made from fatty acids.
Ketones are acidic
Eventually all of the extra bicarbonate from the kidneys is used up from the ketones leading to the blood becoming acidotic
Why do you get dehydration and Polyuria with Diabetic Ketoacidosis?
Kidney unable to filter glucose back into the blood. Lots of glucose remains in urine, this draws lots of water into the urine via OSMOTIC DIURESIS
Patient urinates a lot removing lots of water from the body making them very dehydrated and so thirsty
Why do you get potassium in balance with DKA?
Insulin normally drives potassium into cells for storage. Without it you can get severe hyperkalaemia.
Then when treating DKA you can push a patient into severe hypokalaemia
What are the 3 diagnostic criteria for Diabetic Ketoacidosis (DKA)?
Ketones > 3mmol
Blood glucose > 11mmol
pH < 7.3
(Bicarbonate < 15mmol)
What is the anion gap for DKA?
High anion gap acidosis > 12
What is the management process for DKA?
A-E assessment
Fluid resuscitation
FBC
U+E
VBG
ECG
CXR
When managing DKA, what drug other than insulin would you give and why?
LMWH (enoxaparin)
DKA is a hyper Coagulative state
What is the maximum rate potassium can be given to a patient in an hour?
10mmol/L
What is the general overview of management for DKA?
Fluids (dehydration)
Potassium in fluids (Potassium imbalance)
Fixed rate insulin
Give glucose infusions as well
What is the fluid regime for a patient with DKA?
Bolus them if in shock, otherwise:
1L 0.9% NaCl 1hr
(500ml 0.9%NaCl + KCl 2hrs) x 2
(250ml 0.9%NaCl + KCl 4hrs) x 3
125ml 0.9% NaCl + KCl 8hrs
What is the fixed rate insulin regime given for DKA?
0.1units/kg/hr
What is the target for maintaining K+ in for DKA treatment?
4.5 - 5.5
When is DKA considered being resolved?
Ketones < 0.3mmol
Bicarb > 15
pH > 7.3
What do you do with the insulin dosing once the DKA has resolved?
Switch from fixed rate to variable rate
What are some complications of treating DKA or general complications of DKA?
Infections
Shock
Vascular thrombosis
HYPOGLYCAEMIA
HYPOKALAEMIA
PULMONARY OEDEMA
CEREBRAL OEDEMA
What medication can be given to relieve a cerebral oedma due to fluid treatment of DKA management?
Mannitol
What is the equation for anion gap?
Anion gap = (Na+ + K+) - (Cl- + HCO3-)
How can you use the anion gap to rule out DKA?
Normal anion gap excludes DKA
with DKA the excess glucose will make the anion gap large
What is a Hyperosmolar Hyperglycaemic State (HHS)
State of extreme hyperglycaemia, dehydration and altered consciousness
How is Hyperosmolar Hyperglycaemic State diagnosed?
Dehydration/hypovolaemia
Glucose > 30mmol
No acidosis or ketones
Osmolality > 320mmol. (VEYR CONCENTRATED)
What is the equation for osmolality?
What osmolality does a pateitn have to have to diagnose Hyperosmolar Hyperglycamic state?
Osmolality = 2(Na + K) + glucose + urea
Osmolality > 320mmol
How does a Hyperosmolar Hyperglycaemic State present?
Extrem dehydration
Hypotension
Confusion
Coma
Neurological issues like seizures
How is Hyperosmolar Hyperglycaemic State managed?
A-E assessment
Give lots of fluids (3-6L over 12hrs)
Correct electrolyte imbalances
What is the insulin regime for treating HHS?
Only give it if ketones are present
What are some complications of managing HHS?
Potassium imbalances
Cerebral odema
What is the most common side effect of insulin?
Hypoglycaemia
What are the risk factors for developing hypoglycaemia?
Insulin or sulfonylurea therapy
Old
Malnourished
Dementia
HF
Depression
Stroke
Chronic hepatic or renal dysfunction
HYPOGLYCAEMIC UNAWARENESS
What is hypoglycaemic unawareness?
Patietn doesn’t feel. Unwell despite BG < 4mmol
How do you manage hypoglycaemia in a pateitn that is conscious and aware?
Get them to drink fruit juice or take some dextrose tablets
When do you give glucagon orIV glucose in a patient with hypoglycaemia when they are conscious and aware?
If BG < 4mmol after 45mins
What is the management for a hypoglycaemic patient that is conscious but can’t tolerate oral medication?
IM glucagon injection
What is the management for an unconscious hypoglycaemic patient?
Stop IV insulin
10% glucose 200ml for 10mins (IV)
How does hypoglycaemia present?
Drowsy
Unconscious
Altered mental state
