Diabetic Emergencies

Question 1

Ketone bodies are formed where?

Answer 1

Liver mitochondria

Question 2

Ketone bodies are derived from which chemical?

Answer 2

Acetyl-CoA

Question 3

DKA is rare in T2DM, why?

Answer 3

Insulin prevents ketone body overload (by inhibiting lipolysis & hence production of acetyl-CoA from fats) and T2DM often have residual insulin

Question 4

When is Acetyl-CoA diverted into ketone bodies?

Answer 4

When there is no oxaloacetate available for it to enter the TCA

Question 5

List 3 ketone bodies

Answer 5

1) Acetone
2) Acetoacetic acid
3) Beta-hydrobutyric acid

Question 6

DKA only occurs in T1DM. True/false?

Answer 6

False

Question 7

Counter-regulatory hormones are increased/decreased in DKA. True/false?

Answer 7

True

Question 8

The underlying cause of DKA is…

Answer 8

An absolute or relative insulin deficiency

Question 9

How does DKA lead to ketogenesis? (3)

Answer 9

1) A lack of insulin increases counter-regulatory hormones.
2) These hormones encourage lipolysis.
3) Fatty acids are brought to the liver, where they are made to ketones for emergency energy.

Question 10

Blood glucose is usually low/normal/high in DKA?

Answer 10

High (but euglycaemic DKA exists)

Question 11

On a dipstick, how many +’s would indicate significant ketonuria?

Answer 11

> 2

Question 12

What 3 factors need to be tested for a diagnosis of DKA to be made?

Answer 12

Ketones in blood, blood glucose, bicarbonate/ pH

Question 13

Bicarbonate is usually < what in DKA?

Answer 13

<15mmol/L (gives pH <7.3)

Question 14

Describe the common precipitants of DKA (4)

Answer 14

1) Infection
2) Illicit drugs + alcohol
3) Non-adherence to treatment (majority)
4) Newly diagnosed diabetes

Question 15

What are the osmotic symptoms of DKA?

Answer 15

Thirst, polyuria, dehydration

Question 16

What are the ketone symptoms of DKA?

Answer 16

Flushing, vomiting, abdominal pain, Kussmaul’s respiration (although not all patients can smell this), bad taste in mouth

Question 17

Lactate is often raised/lowered in DKA?

Answer 17

Raised

Question 18

In DKA, a raised amylase is a sign of pancreatitis?

Answer 18

No, it’s often salivary in origin

Question 19

What’s a cause of death in children with DKA?

Answer 19

Cerebral oedema

Question 20

What’s a cause of death in adults with DKA? (3)

Answer 20

ARDS, aspiration pneumonia, hypokalaemia.

Question 21

In the HDU, DKA is managed by fluid replacement initially. Which fluid is given? What is switched to?

Answer 21

0.9% sodium chloride initially, then switch to dextrose once glucose falls to around 15mmol/L

Question 22

DKA patients should be given potassium and insulin, true/false?

Answer 22

True

Question 23

In DKA, phosphate and bicarbonate are frequently replaced, true/false?

Answer 23

False

Question 24

Which ketone type is measured in urine?

Answer 24

Acetoacetate

Question 25

Ketones in urine lag behind blood ketones by how long?

Answer 25

2-4 hours

Question 26

After an episode of DKA, it is normal to have persisting ketonuria. True/false?

Answer 26

True (ketones are mobilised from fat tissue)

Question 27

Hyperglycaemic hyperosmolar syndrome occurs in youth/elderly?

Answer 27

Elderly

Question 28

HHS often presents in those who’s diabetes is dietary-lone managed. True/false?

Answer 28

True

Question 29

HHS is usually preceded by what event?

Answer 29

High intake of CHOs

Question 30

HHS can be precipitated by what factors? (2)

Answer 30

1) CV event

2) Sepsis

Question 31

HHS is defined as which 3 factors being present? (3)

Answer 31

1) Hypovolaemia
2) Hyperglycaemia (BG>30mmol/L without acidosis or ketonaemia)
3) Hyperosmolar

Question 32

The BG is often higher in HHS than DKA, true or false?

Answer 32

True

Question 33

HHS presents with significant X impairment.

Answer 33

X = renal

Question 34

Ketones are raised in HHS higher than DKA. True/false?

Answer 34

False

Question 35

HHS is commoner in which type of DM?

Answer 35

T2DM

Question 36

What has higher mortality - DKA or HHS?

Answer 36

HHS

Question 37

How is HHS treated? (3)

Answer 37

Dietary intervnetion, hypoglycaemic drugs, insulin.

Question 38

HHS patients should be given insulin faster than those in DKA. True/false?

Answer 38

False (some patients do not even require insulin)

Question 39

Fluids should be given rapidly in HHS. True/false?

Answer 39

Slowly (risk of overload)

Question 40

Lactate is produced where (4)

Answer 40

Red blood cells, muscle, brain, renal medulla

Question 41

Lactate is cleared via the

Answer 41

Liver

Question 42

Lactate is converted to what?

Answer 42

Pyruvate (then into glucose)

Question 43

Type A lactic acidosis occurs in response to…

Answer 43

Tissue hypoxia (e.g. infarcted tissue, hypovolaemic shock, sepsis)

Question 44

Type B lactic acidosis occurs in response to…

Answer 44

Liver disease, diabetes.

Question 45

Treatment of lactic acidosis (2)

Answer 45

1) Fluids

2) Antibiotics

Question 46

What is a non-insulin related cause of ketoacidosis?

Answer 46

Alcohol

Question 47

How is alcoholic ketoacidosis treated? (2)

Answer 47

1) Pabrinex
2) IV fluids (esp. dextrose)

Rarely insulin

Question 48

What’s the main difference between regular DKA & euglycaemic DKA?

Answer 48

Euglycaemic has a lower BG (<15mmol/L)

Question 49

What should the HbA1c be before elective surgery is carried out?

Answer 49

<75mmol/L