Diabetic Emergencies Flashcards
What are the tests that can diagnose diabetes?
Positive oral glucose tolerance test - gold standard
Fasting blood glucose
HbA1c
Serum glucose level
Why isn’t the capillary glucose test used for diagnosing diabetes?
Because there’s a lag between it and serum glucose
What are the conditions required for a diagnosis of diabetic ketoacidosis?
Hyperglycaemia
Acidosis
Ketoacidosis
Which is more specific: blood or urine ketone levels?
Blood ketone levels
What are the precipitating factors of diabetic ketoacidosis?
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
What are the treatment principles for ketoacidosis?
Resuscitation Rehydration Correct electrolyte imbalance Insulin therapy Search for underlying cause
Why is insulin therapy important in the treatment of ketoacidosis?
To switch of ketogenesis
What are the principles of rehydration in the treatment of ketoacidosis?
Individualised for each patient
In 1st 4 hours, give 3 L of normal saline
Change to 10% dextrose + insulin when glucose <=12 mM
What are the principles of potassium balance in the treatment of ketoacidosis?
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
What other electrolytes should be replaced in the treatment of ketoacidosis?
Bicarbonate
Phosphate
What happens to the pH when bicarbonate is administered?
Transient rise in pH > drop as kidneys excrete infused bicarbonate
What are the principles of insulin in the treatment of ketoacidosis?
Continue infusion until acidosis and ketogenesis resolved
When do you stop IV insulin in the treatment of ketoacidosis?
Resolve acidosis
Stop ketogenesis
Started eating and drinking
How do you switch to subcutaneous insulin in the treatment of ketoacidosis?
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
What is pseudohyponatraemia with hyperglycaemia?
Na levels higher than what the blood test shows in setting of hyperglycaemia
What was hyperglycaemic hyperosmolar state (HHS) previously known as?
Hyperosmolar non-ketotic coma (HONK)
What are the diagnostic criteria for HHS?
Severe hyperglycaemia Minimal ketosis/ketoacidosis Profound dehydration Depressed sensorium/coma Effective osmolarity >330 mOsm/kg
What is the treatment for HHS?
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
Why is heparin administered prophylactically in the treatment of HHS?
Hyperosmolarity a risk factor for venous thrombotic events - and sometimes even arterial thrombotic events
What usually determines conscious state in terms of hyperglycaemia?
Osmolarity, not degree of acidosis
What should you do if the patient has a severely depressed conscious state and their osmolarity is not >330 mOsm?
Look for another cause
How do you treat hypoglycaemia if the patient is conscious and cooperative?
Oral fluids containing sugar
How do you treat hypoglycaemia if the patient is unconscious or at risk of aspiration?
IV 50% dextrose via antecubital vein
IM/SC glucagon 1 mg
When can’t intramuscular injections be administerd?
If patients are anticoagulated
What happens if you burst the vein when administering glucose?
Necrosis to surrounding tissue
After the immediate administration of glucose in a hypoglycaemic case, what do you do?
Administer longer acting carbohydrate; eg: sandwich
Recheck glucose 20-30 mins later and administer further treatment if required
How do you manage a case of hyperglycaemia?
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
How do you avoid a hyperglycaemic emergency?
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
How do you avoid a hypoglycaemic emergency?
Always carry form of sugar
Appropriate adjustment of glucose lowering therapies
What is the ankle brachial index?
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
What is the critical management of an extremely painful, cold foot?
Ensure not critical limb ischaemia
Exclude osteomyelitis
Is plain x-ray good at finding osteomyelitis?
Yes, it is, but if it’s normal, can’t exclude osteomyelitis
What is the use of MRI and bone scans in diagnosing osteomyelitis?
Finds bone marrow oedema
Excludes osteomyelitis
