Diabetic emergencies

Question 1

What is needed to diagnose diabetic ketoacidosis?

Answer 1

Ketonaemia of over 3mmol/l or 2+ ketonuria or a result of 2+ on a standard urine stick
Bloood glucoseof over 11mmol/l or known diabetes
Bicarbonate of under 15mmol/l or venous pH of under 7.3

Question 2

Levels of what hormones increase when the body is in DKA?

Answer 2

Glucagon, adrenaline, cortisol and growth hormone

Question 3

What bicochemical markers are usually high when a patient comes in with DKA?

Answer 3

Potassium
Lactate
Creatinine

Question 4

What biochemical marker is usually low in DKA?

Answer 4

Sodium

Question 5

Describe what usually happens to sodium and potassium in DKA?

Answer 5

High potassium (above 5.5) and low sodium

Question 6

What substance do you measure in the blood to meausure ketones?

Answer 6

Beta hydroxybutarate

Question 7

Are bicarbonate levels low or high in DKA?

Answer 7

Low

Question 8

How would you manage DKA?

Answer 8

1. 0.9% saline
   - If glucose falls to 15 switch to dextrose
2. Insulin
3. Potassium
   (4) Sometimes phsophate
   - Monitor potassium
   Heparin

Question 9

How long do you give saline over and how much do you give for DKA?

Answer 9

1L 0.9% over 1hr

Question 10

How much insulin fo you want to give for a patient in DKA

Answer 10

6units/hour IV soluble insulin

Question 11

What does the pottassium need to be under in order for you to give pottassium in DKA?

Answer 11

5mmol/L

Question 12

If the blood glucose falls to below 14 in the first four hours of DKA treatment, what do you do?

Answer 12

Give glucose 10% 500ml with 20mmol KCl at 100ml/hour

Reduce insulin to 3 units an hour

Question 13

What do you want to maintain the blood sugar at in treatment of DKA?

Answer 13

Between 9 and 14

Question 14

What does urinary ketones measure?

Answer 14

Acetoacetate

Question 15

On biochemistry a diabeteic patient has a high ion gap yet low ketone levels

Answer 15

Lactic acidosis

Question 16

How do you get type A lactic acidosis?

Answer 16

Tissue hypoxaemia eg ischaemic bowel, sepsis

Question 17

What drugs could cause lactic acidosis in diabetic patients?

Answer 17

Metformin

Question 18

Is type A or type B lactic acidosis most associated with diabetes?

Answer 18

Type B

Question 19

What is the equation to work out a raised ion gap?

Answer 19

[(Na+ + K+) – (HCO3 + Cl-)]

Question 20

What are the phosphate levels like in lactic acidosis?

Answer 20

Raised

Question 21

What medication increase the risk of hyperosmolor hyperosmotic syndrome?

Answer 21

Glucocorticoids and thiazides

Question 22

A 78 year old lady.
Practice phoned by relatives asking for a home visit. Known metastatic breast cancer with increasing confusion over a week. History of diet-controlled type 2 diabetes.
morphine, dexamethasone [recently started]

BM when visited – “HI” on meter

Answer 22

Hyperglycaemic hyperosmolar syndrome

Question 23

How high in the glucose in HHS?

Answer 23

Very high; often above 60

Question 24

What is the usual osmolality in HHS?

Answer 24

400

Question 25

How do you treat HHS?

Answer 25

Slowly give fluids
Give insulin at 3 units per hour
Monitor sodium

Question 26

Is sodium usually high or low in HHS?

Answer 26

High

Question 27

What is the main worry with HHS?

Answer 27

Cerebral oedema