Diabetic emergencies Flashcards
What is the diagnostic criteria for diabetic ketoacidosis (DKA)?
An emergency diabetes complication, characterised by:
-
Hyperglycaemia >11mmol/L; or known DM
- Euglycaemic DKA can occur with SGLT-2 inhibitors
- Acidosis: bicarb <15mmol/L and/or venous pH <7.3
- Significant ketonuria (2+) or ketonaemia (>3mmol/L)
List five possible triggers of DKA
- Infection
- Discontinuation of insulin
- Inadequate insulin
- Cardiovascular disease
- Drugs:
- Steroids, sympathomimetics, A-blockers, B-blockers, diuretics, SGAs, SGLT2i
- Stress: Surgery, trauma, pregnancy
- Chemotherapy
Describe the presentation of DKA
Initial: Polyuria; polydipsia; vomiting; dehydration; abdominal pain
Severe: Altered mental state; coma (5%)
Additional: Acetone breath (pear drop); Kussmaul breathing/tachypnoea; weight loss; weakness; lethargy
Temperature is often subnormal even in presence of infection.
List three symptoms or signs of mild-moderate dehydration
- Increased thirst
- Tiredness
- Dizziness/headache
- Oliguria
- Dry mucous membranes
- Sunken eyes
- Postural hypotension
- Reduced skin turgor
- Delayed capillary refill
List five signs of severe dehydration
- Weakness
- Confusion; coma
- Tachycardia with weak pulse
- Hypotension
- Anuria
How may DKA present on NEWS score?
- EWS >6
- Pulse >100 bpm or <60 bpm
- SBP <90 mmHg
- GCS <12 or abnormal AVPU
- SaO2 <92%
Give five investigations in suspected DKA?
- Urine dip: ketonuria (2+); glycosuria
- ABG/VBG: pH <7.0
- VBG: HCO3 <5mmol/L
- Capillary and serum blood glucose
- Blood ketones >6mmol/L or ketonuria
- U+E: K+ <3.5mmol/L
- ECG; MI screen
- CXR
- MSU; blood cultures
Outline the immediate management of DKA
- A-E assessment
- If severe: immediate senior review; consider HDU/ITU
- IV access and 0.9% sodium chloride infusion
- Fluid resus if SBP <90
- 1st litre (1h); subsequent 2L (4h); 2L (8h); 2L (12h)
-
Potassium replacement
- >5.5: nil
- 3.5-5.5: 20mmol/500mL
- <3.5: senior review
-
Fixed rate IV insulin (Actrapid) [0.1 units/kg/h] ± IM/SC STAT dose
- Hourly ketone and CBG monitoring
- Continue any long acting insulin
- Add 10% glucose if CBG <14mmol/L
When is DKA considered to be resolved?
What subsequent management should occur once resolved?
Resolved DKA
- Venous pH >7.3; and/or
- Blood ketones <0.6mmol/L
Subsequent management
- Review insulin infusion: target CBG 5-10mmol/L
- Encourage oral intake and switch to SC insulin
- Otherwise switch to VRII
- Refer to specialist diabetes team
What is Hyperosmolar hyperglycaemic state (HHS)?
T2DM emergency characterised by:
- Hyperglycaemia
- Hyperosmolarity
- Dehydration
- Without significant ketoacidosis.
List 5 potential triggers for HHS
Co-morbidities: MI, infection, stroke/TIA, pancreatitis, PE, GI bleed, Cushing’s syndrome
Drugs: Metformin, thiazide diuretics, B-blockers, CCBs, dialysis, steroids, alcohol
Diabetes: Poor control, non-compliance, consumption of glucose-rich fluids
Describe the presentation of HHS
Characteristic: dehydration and stupor/coma
Initial: dehydration, polyuria, polydipsia, weakness, leg cramps, visual impairment
Severe: lethargy, confusion, coma (rare)
Additional: Seizures
Outline the management of HHS
- Rehydrate slowly with 0.9% saline over 48h
- avoids cerebral damage
- Replace K+ when urine output improves
- Insulin if glucose not falling by 5 mmol/L
- Maintain glucose 10-15 mmol/L in first 24h
- avoid cerebral oedema (rapid reduction of osmolarity causes reversal of fluid shift)
- Prophylactic LMWH and TED stockings
What medication is associated with lactic acidosis in diabetes?
Metformin
When should lactic acidosis be suspected over DKA?
Severe metabolic acidosis with large anion gap Usually without significant hyperglycaemia or ketosis
