Diabetic Emergencies Flashcards by Hannah Meiklejohn

What HbA1c should be aimed for to prevent microvascular complications? What if there is a high risk of arterial disease?

Less than 7.0%

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How often should HbA1c be checked?

Every 2-3 months?

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What immediate actions should be taken in a case of suspected hypoglycaemic coma

Stat IV glucose

Pre-hospital IM glucagon can be used if liver glycogen stores are adequate

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Why can’t T1DM be managed with oral hypoglycaemics?

If there are no B cells in the pancreas (due to anti-islet autoimmunity in T1DM), it cannot be stimulated to increase insulin production (which is the mechanism of action of most oral hypoglycaemics)

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What conditions may induce a secondary DM?

Chronic pancreatitis
Pancreatic Ca
Pancreactectomy
Haemochromatosis
CF
Cushings syndrome
Acromegaly

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What are the 3 emergency presentations related to DM?

DKA (most common)
Hyperosmolar hyperglycaemic state (HHS; also hyperglycaemic )
Hypoglycaemic coma

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What are some possible underlying causes of hypoglycaemic emergency in patients who are not diabetic?

Deliberate self-harm (overdose?)
EtOH
Liver disease
Sepsis
Starvation (anorexia nervosa)
Damping syndrome
Adrenal insufficiency
Islet cell tumour

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What symptoms are seen when plasma glucose falls below normal levels?

Neurological and mental dysfunction

Hypothermia, depression, psychosis (less common)

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List some clinical features of DKA

Malaise and fatigue
Polyuria, polydypsia, weight loss
GI symptoms (nausea, abdominal pain)
Kussmaul breathing (deep, fast breaths with periods of apnoea)
Characteristic "sweet-smelling" breath
Reduced conscious level or coma

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What is the most common underlying cause of DKA (where diabetic management is normal)?

Infection

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How can the presentation of sepsis differ in diabetics?

Can present without fever in diabetics

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DDx for diabetic emergencies

Alcoholic or starvation ketoacidosis
Lactic acidosis
Renal failure
EtOH, methanol or salicylate infestion
HHS/HHNK
Hyperglycaemia without DKA or HHNK

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Ix for diabetic emergencies

VBG and venous pH hourly
UEC hourly (look at potassium; decreases with treatment because insulin pushes extracellular K+ intracellularly; initially may be increased due to effect of pH but may also be normal)
FBE (mild leukocytosis common), CRP
LFT, lipase
Urinalysis
ECG (risk with metabolic imbalances esp K+; may be silent AMI)
CXR
Point of care testing of capillary glucose and ketones

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DKA

Hyperglycaemia rarely >40 mmol/L
Metabolic acidosis (bicarb

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DKA Mx

Good Hx
ABCDE
Close monitoring equipment (CVP monitoring if significant CVD), airway protection, NGT when GCS impaired, O2
Early aggressive volume resuscitation if shock (if not in shock still require rehydration, aim to give IVF within 30 mins of arrival to ED: 0.9% normal saline 500ml/hr for 4 hrs, then 250ml/h for 4 hrs - replace the volume deficit, often 10% of body weight, within 24 hrs unless comorbidities), changing to 5% dextrose when glucose lowers to 12mM
Correct electrolyte imbalance
Search for underlying cause

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Why is fluid resuscitation so important in the management of hyperglycaemic emergencies?

Severe fluid loss (polyuria) as a result of hyperglycaemia

HHNK Mx

Fluids: 2L hypotonic saline (0.45%) over 1-2 hrs, 1L 2-3 hrly
Monitor UO and CVP if indicated
Initial dose of insulin 0.05U/kg/hr (max 3 units; go slower than DKA) and reduce insulin infusion rate when glucose drops below certain level
Monitor K+
Give prophylactic heparin (no evidence but a good idea)
Search for underlying cause

Underlying causes of hypoglycaemia

Rx change or error
Inadequate intake
Excessive exercise
Deliberate self harm
EtOH (reduces gluconeogenesis)
Sepsis
Starvation

Symptoms of hypoglycaemia

Neurological and mental dysfunction
Diaphoresis
Tremor
Hunger (polyphagia)
Tachycardia, tachypnoea
Confusion or agitation
Less commonly hypothermia
Depression
Psychosis

Symptoms of hyperglycaemia

Polyuria
Polydipsia
Polyphagia

What should you do when managing a patient if you are unsure whether they are hypoglycaemic or hyperglycaemic?

Give sugar (hypo is riskier than hyper so it doesn’t really matter if you give sugar to someone who is hyperglycaemic), wait at least 10 mins and see if they improve

Hypoglycaemic coma Mx

Hx (look for clues)
ABC
Give 50ml 50% glucose IV or 0.5-2 mg glucagon IM

Electrolytes in hypoglycaemic coma

Osmolarity = (2 x Na+) + glucose + urea (mmol/L)
Corrected Na level = measured Na + 1/3(glucose-10)
Calculate the anion gap (Na+K)-(Cl+bicarb)
Urgent K+ level

General points for managing diabetic emergencies

Sick diabetic patient consider early referral to endocrinology
Systemically very unwell patient (hypotensive, septic or decreased GCS), early referral to ICU
Education
Dietitian referral
Diabetic educator

23 year old female, works as PA, experiencing tiredness for 4/52, 5kg LOW, thirst with polyuria and blurred vision for last week, intermittent vomiting for 2/7 and mild abdominal pain in last 24 hours O/E: alert but lethargic, HR 140, BP 90/70, RR 40 with Kussmaul respiration, clinically dehydrated, generalised abdominal tenderness FWT: glucose 4+, ketones 4+ Dx? Ix?

Likely DKA | Ix: glucose, UEC, ABGs, ketones

23 year old female presents with Sx of DKA Glucose: 47mmol/L UEC: Na+ 140, K+ 4.2, Cl- 111, HCO3- 5, Cr 180 ABGs: pO2 143, pCO2 11, pH 6.98 What blood and urine ketone level suggests developing ketoacidosis?

0.6-1.5mmol/L or urine ketone + suggests developing ketoacidosis which may be able to be treated with extra insulin >1.5mmol/L in blood and ++ or more in urine - contact health professional urgently!

List 9 possible precipitating factors for DKA

``` New onset T1DM Inadequate/inappropriate insulin therapy Alcohol abuse Infection: pneumonia, septicaemia, UTI MI/CVA Inappropriate insulin therapy Pancreatitis Drugs (corticosteroids, thiazides) No cause in 20% ```

What fluids should be used in DKA for resuscitation?

NS Might use plasma-lyte (only has 100mM chloride but does contain K+) Change to 5% dextrose when glucose is less than or equal to 12mM

Describe the approach to correcting electrolyte abnormalities in DKA

Aim to maintain K+ between 3.5 and 5mM If K+ less than 3.5, hold off on giving insulin, and give 30mM per hour until K+ is above 3.5 If K is at or above 5mM, do not give K+ but check the K+ level every hour If K is between 3.5 and 5mM, give 30mM KCl in every L of fluid to maintain K+ between 4-5mM Make sure that the pt is not anuric before starting K+ replacement!

When might bicarb replacement be considered in the setting of DKA? What other electrolyte may need correcting?

If very severe acidosis (pH less than 6.8), may occasionally be used in ICU setting (but no evidence to support it yet) Consider correction of phosphate in ICU setting (again no evidence)

What are the guidelines for treating DKA with insulin?

IM regimen: 0.1U/kg/hr of regular insulin IV infusion regimen: initially 6-8U hrly via pump, then adjust according to BSLs and continue infusion until acidosis has resolved THEN switch to SC insulin (e.g. Novorapid/Humalog 4-6U TDS and glargine/determir 6U nocte)

4 rules of treating DKA

Rehydrate Do not give insulin until you know what the K+ is! Correct hyperglycaemia Dx a precipitating factor if possible and treat it

87 year old woman transferred from nursing home with no known Hx of diabetes, experiencing increasing lethargy over a week and now finally unrousable O/E: responds only to painful stimuli, no localising neurological signs, BP 150/90, HR 120, RR 25, clinically very dehydrated Ix: glucose 80, Na+ 150 uncorrected, K+ 4.4, HCO3- 24, urea 20, osmolarity 380 (N 270-300), pH 7.39, no ketonuria How is effective osmolality calculated? Dx?

2(Na+) + glucose | Dx: hyperglycaemic hyperosmolar state (HHS)

What are the clinical features of HHS?

``` Severe hyperglycaemia Minimal ketosis or ketoacidosis Profound dehydration Depressed sensorium or coma Effective osmolarity >330mOsm/kg ```

If a patient has a severely depressed conscious state and their osmolarity is not >330mOsm/kg, what should you do?

Look for another cause! | Osmolarity, not degree of acidosis, usually determines conscious state (although this has been questioned recently)

Compare mortality in DKA vs HHS

Lower in DKA (5%) than HHS (10-15%) | Mainly due to age and comorbidities

9.30pm ward call Mr PO in bed 26 has had a BSL of 1.8mmol/L What next?

Ask if he is alert and capable of taking oral intake safely! If conscious and cooperative: oral fluids containing sugar (e.g. OJ, soft drink, milk with sugar) If unconscious or risk of aspiration: IV 50% dextrose (25-50mL) via antecubital vein, or IM/SC glucagon 1mg (if no IV) Also administer a longer acting CHO e.g. sandwich Recheck glucose 20-30mins later and administer further treatment if required Then figure out why it happened!

What is a possible underlying cause of hypoglycaemia in the hospital setting and how does this present?

Associated with SUs (e.g. glibenclamide): can be prolonged, esp in elderly with renal impairment (BSLs can still dip after initial correction of hypoglycaemia)