Diabetic Emergencies

Question 1

What is hypoglycaemia

Answer 1

Blood glucose <4mmol/l

Question 2

Hypoglycaemia clinical features

Answer 2

Pallor, Sweating, Tremor, Palpitations,
Nausea, Hunger,
Confusion & cognitive impairment, coma

Question 3

Mild hypoglycaemia (conscious) treatment

Answer 3

1. ABCDE
2. Fast acting carbs
3. Slow acting carbs

Question 4

Severe hypoglycaemia (seizure/ unconscious) treatment

Answer 4

1. ABCDE
2. 200ml 10% dextrose IV
   OR (if no IV access) 1mg glucagon IM

Question 5

When will IM glucagon not work in sever hypoglycaemia

Answer 5

If hypoglycaemia is alcohol induced
(Alcohol blocks gluconeogenesis)

Question 6

Does DKA typically occur in T1DM or T2DM

Answer 6

T1DM

Question 7

DKA triggers (5 I’s)

Answer 7

• Infections: pneumonia, UTIs, cellulitis
• Inflammatory: pancreatitis, cholecystitis
• Intoxication: alcohol, cocaine, salicylate, methanol
• Infarction: acute MI, stroke
• Iatrogenic: steroids, surgery

Question 8

What is DKA/ how is it diagnosed

Answer 8

Diabetic - blood glucose >11.1
Ketosis - ketones > 3mmol/l
Acidosis - pH < 7.3 &/ bicarbonate <15

Question 9

What type of breathing does DKA often cause & why

Answer 9

Kussmaul’s respiration: deep, rapid breathing pattern associated with severe metabolic acidosis

Question 10

DKA pathophysiology

Answer 10

Insulin deficiency & hyperglycaemia =>
Beta oxidation of FFAs (lipolysis for energy) =>
Ketone formation => acidosis

Insulin deficiency & hyperglycaemia =>
Increased glucose urine excretion =>
Thirst, polyuria & dehydration => exacerbated acidosis

Question 11

DKA clinical presentation

Answer 11

• Thirst & polyuria & dehydration (osmotic related)
• Vomiting, abdominal pain (ketoacidosis related)
• Kussmauls RR, distinctive fruity smell (ketoacidosis related)
• Altered mental state (mixed cause)
• Severe hyperglycaemia symptoms

Question 12

DKA biochemistry summary

Answer 12

• Low insulin & high glucose (diabetic)
• High glucagon, cortisol, adrenaline, GH (diabetic)
• High gluconeogenesis/ FFA beta oxidation (lipolysis/ketosis)
• High ketones, low pH & bicarbonate (acidosis)

Question 13

DKA management

Answer 13

1. IV fluids 0.9% saline 1L/hr
2. IV insulin 0.1 units/kg/hr
3. Correct electrolytes e.g. IV K

• Once blood glucose falls to <14mmol/l add IV glucose 10%
• Continue long acting insulin throughout!
• Stop rapid acting insulin
• Regular monitoring & treat underlying conditions
• antibiotics if infection
• NG tube if vomiting/ reduced consciousness

Question 14

In DKA, what monitoring would you want to carry out

Answer 14

Blood ketones & glucose hourly
Blood gases & U&Es 2 hourly

Question 15

DKA complications in kids

Answer 15

cerebral oedema

Question 16

DKA complications in adults

Answer 16

Hypokalaemia => cardiac arrest, paralytic ileus
Aspiration pneumonia
ARDS
VTE & PE

Question 17

What is HHS and who does it usually affect

Answer 17

Hyperglycaemic hyperosmolar syndrome
Typically in T2DM

Question 18

HHS pathophysiology

Answer 18

Similar to DKA
But small amounts of insulin still released from pancreas
This prevents ketoacidosis by suppressing lipolysis

Question 19

HHS diagnostic features/ investigations

Answer 19

• Severe hyperglycaemia (glucose > 33mmol/l)
• Hyperosmolarity (serum osmolarity >320mmol/kg)
• Volume depletion/ marked dehydration
• No ketoacidosis

Question 20

HHS clinical presentation

Answer 20

• N&V, Polydipsia (hyperglycaemia)
• Dehydration, polyuria, coma (hyperosmolarity)

Question 21

HHS management

Answer 21

1. IV fluids 0.9% saline
2. Monitor glucose, osmolarity & Na
   a. Reduce saline to 0.45% if rapid Na fluctuations
   b. Only add insulin if ketones >1 or glucose lowering too slow
3. Screen for comorbidities, check feet & start on LMWH

Question 22

How do you calculate serum osmolarity

Answer 22

2(Na + K) + Glucose + Urea

Question 23

HHS complications

Answer 23

CV => check from silent MI, start on LMWH etc
Feet => check feet!