Diabetic Emergencies

Question 1

Which of the following are true about DKA and HHS?
A. Both are caused by a lack of insulin
B. Both are associated with dehydration
C. Both can occur in type 1 and type 2 diabetes
D. All of the above

Answer 1

D. All of the above

Question 2

A 78 year old man has a history of T2D and renal failure. He appears severely dehydrated. His lab work shows hyperglycaemia, hypernatremia, but no acidosis and no ketosis. This indicates NO evidence of:
A. Gluconeogenesis
B. Glycogenolysis
C. Osmotic diuresis
D. Lipolysis

Answer 2

D. Lipolysis

Question 3

What are the counter-regulatory hormones to insulin that are increased in DKA/HHS?

Answer 3

Counter-regulatory hormones: glucagon, cortisol, GH, epinephrine. These will inhibit insulin-mediated glucose uptake by muscle, activate glycogenolysis and gluconeogenesis, active lipolysis and inhibit insulin secretion.

Question 4

A 78 year old man living on his own found in his bed un-rousable. He has a history of T2D and renal failure. His blood glucose is HIGH on a meter check. He appears severely dehydrated. Based on this history he is most likely to have:
A. DKA
B. HHS

Answer 4

B. HHS

Question 5

A 12 year old girls with T1D presents with DKA. Her mom is a single mom and has not been able to supervise diabetes care. She has a fever and complains of dysuria. Precipitants of DKA include:
A. Unsupervised diabetes care in a child & non-compliance
B. Relative insulin deficiency
C. Acute illness
D. All of the above

Answer 5

D. All of the above

Question 6

You are examining a 10 year old girl who was admitted for new onset T1DM with DKA last night. On exam, she has a new onset right sided hemiparesis. What do you think happened?
A. She has developed hypocalcemia.
B. She has developed thrombotic stroke.
C. She has developed hypophosphatemia.

Answer 6

B. Focal onset of neurological symptoms indicate thrombotic stroke.

Question 7

What is the treatment for DKA?

Answer 7

DKA treatment in adults:

1. FLUID RESUSCITATION (normal saline 1-2L as a bolus in the ER and then after that slower rehydration over 48 hours)
2. Frequent blood tests (q1-2 hours initially; electrolytes, anion gap, osmolality, glucose, gas)
3. Avoid hypokalemia: make sure patient has urine output and then give IV K+ as soon as serum K+
4. Give insulin as bolus at 0.1 units/kg/hour
5. Avoid rapidly falling serum osmolality (give Na+)
6. Search for precipitating cause
7. Give bicarbonate if pH>6.9, severe shock, or life-threatening hyperkalemia

Question 8

What is the treatment for HHS?

Answer 8

HHS treatment in adults:

1. Fluid resuscitation ( normal saline bolus 1-2L/hr, aim to correct total fluid deficit slowly over 48 hours)
2. Frequent blood tests (q1-2 hours)
3. Search for precipitating cause
4. Consider insulin therapy to further reduce hyperglycaemia if needed

Question 9

What are the potential treatment related complications of DKA/HHS?

Answer 9

Treatment related complications: cerebral edema, pulmonary edema, hypoglycaemia (seizures), hypokalemia (dysrhythmias)

Question 10

What are the potential non-treatment related complications of DKA/HHS?

Answer 10

Complications of DKA/HHS: thrombotic stroke, DVT, PE, pancreatitis, renal failure