Diabetic Emergencies

Question 1

What are the tests that can diagnose diabetes?

Answer 1

Positive oral glucose tolerance test - gold standard
Fasting blood glucose
HbA1c
Serum glucose level

Question 2

Why isn’t the capillary glucose test used for diagnosing diabetes?

Answer 2

Because there’s a lag between it and serum glucose

Question 3

What are the conditions required for a diagnosis of diabetic ketoacidosis?

Answer 3

Hyperglycaemia
Acidosis
Ketoacidosis

Question 4

Which is more specific: blood or urine ketone levels?

Answer 4

Blood ketone levels

Question 5

What are the precipitating factors of diabetic ketoacidosis?

Answer 5

1st presentation of type 1 diabetes
Inadequate/inappropriate insulin therapy
- Just not taking insulin not enough > need another injury
Infections
Psychosocial stressors
Myocardial infarction
Pancreatitis
Drugs
Unknown

Question 6

What are the treatment principles for ketoacidosis?

Answer 6

Resuscitation
Rehydration
Correct electrolyte imbalance
Insulin therapy
Search for underlying cause

Question 7

Why is insulin therapy important in the treatment of ketoacidosis?

Answer 7

To switch of ketogenesis

Question 8

What are the principles of rehydration in the treatment of ketoacidosis?

Answer 8

Individualised for each patient
In 1st 4 hours, give 3 L of normal saline
Change to 10% dextrose + insulin when glucose <=12 mM

Question 9

What are the principles of potassium balance in the treatment of ketoacidosis?

Answer 9

Maintain K between 3.5-5 mM
If K <3.5 mM - replace K first
If K >5 mM - don’t give K > monitor every hour
Make sure patient not anuric before starting K replacement

Question 10

What other electrolytes should be replaced in the treatment of ketoacidosis?

Answer 10

Bicarbonate

Phosphate

Question 11

What happens to the pH when bicarbonate is administered?

Answer 11

Transient rise in pH > drop as kidneys excrete infused bicarbonate

Question 12

What are the principles of insulin in the treatment of ketoacidosis?

Answer 12

Continue infusion until acidosis and ketogenesis resolved

Question 13

When do you stop IV insulin in the treatment of ketoacidosis?

Answer 13

Resolve acidosis
Stop ketogenesis
Started eating and drinking

Question 14

How do you switch to subcutaneous insulin in the treatment of ketoacidosis?

Answer 14

Wait to next meal
Dose of short-acting insulin
Wait 30 min
Switch off IV insulin
If already on insulin therapy, administer long-acting insulin when switching off IV insulin

Question 15

What is pseudohyponatraemia with hyperglycaemia?

Answer 15

Na levels higher than what the blood test shows in setting of hyperglycaemia

Question 16

What was hyperglycaemic hyperosmolar state (HHS) previously known as?

Answer 16

Hyperosmolar non-ketotic coma (HONK)

Question 17

What are the diagnostic criteria for HHS?

Answer 17

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

Question 18

What is the treatment for HHS?

Answer 18

Fluids
Monitor urine output
Insulin
Potassium
Prophylactic heparin
- Treatment dose of low molecular weight heparin
Search for underlying cause
Avoid rapid correction of hyperglycaemia
- Only halve glucose levels in 1st 24 hours

Question 19

Why is heparin administered prophylactically in the treatment of HHS?

Answer 19

Hyperosmolarity a risk factor for venous thrombotic events - and sometimes even arterial thrombotic events

Question 20

What usually determines conscious state in terms of hyperglycaemia?

Answer 20

Osmolarity, not degree of acidosis

Question 21

What should you do if the patient has a severely depressed conscious state and their osmolarity is not >330 mOsm?

Answer 21

Look for another cause

Question 22

How do you treat hypoglycaemia if the patient is conscious and cooperative?

Answer 22

Oral fluids containing sugar

Question 23

How do you treat hypoglycaemia if the patient is unconscious or at risk of aspiration?

Answer 23

IV 50% dextrose via antecubital vein

IM/SC glucagon 1 mg

Question 24

When can’t intramuscular injections be administerd?

Answer 24

If patients are anticoagulated

Question 25

What happens if you burst the vein when administering glucose?

Answer 25

Necrosis to surrounding tissue

Question 26

After the immediate administration of glucose in a hypoglycaemic case, what do you do?

Answer 26

Administer longer acting carbohydrate; eg: sandwich

Recheck glucose 20-30 mins later and administer further treatment if required

Question 27

How do you manage a case of hyperglycaemia?

Answer 27

Does the patient have type 1 or type 2 diabetes?
How is the patient feeling
- Nausea and vomiting - could indicate development of diabetic ketoacidosis
Why is the patient hyperglycaemic?
Manage and treat hyperglycaemia
- Correction dose of rapid-acting insulin
- Recheck glucose every 1-2 hours
- Repeat dose if glucose not dropping
- If patient has T1D
- Check ketones
- Start fluids if appropriate

Question 28

How do you avoid a hyperglycaemic emergency?

Answer 28

If have type 1 diabetes, never omit long-acting insulin
Education
- Sick day management
- Monitoring ketones
- Supplemental short-acting insulin regimes
Need more not less insulin when unwell

Question 29

How do you avoid a hypoglycaemic emergency?

Answer 29

Always carry form of sugar

Appropriate adjustment of glucose lowering therapies

Question 30

What is the ankle brachial index?

Answer 30

Systolic blood pressure at ankle divided by systolic blood pressure at brachial artery = 1
If ankle pressure higher - calcification of arteries - common in diabetics
If brachial artery pressure higher - decreased blood flow to feet

Question 31

What is the critical management of an extremely painful, cold foot?

Answer 31

Ensure not critical limb ischaemia

Exclude osteomyelitis

Question 32

Is plain x-ray good at finding osteomyelitis?

Answer 32

Yes, it is, but if it’s normal, can’t exclude osteomyelitis

Question 33

What is the use of MRI and bone scans in diagnosing osteomyelitis?

Answer 33

Finds bone marrow oedema

Excludes osteomyelitis