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Endocrine- Diabetes > Diabetic Emergencies > Flashcards

Diabetic Emergencies Flashcards

1
Q

Why does hypoglycaemia occur?

A

As a result of an imbalance between injected insulin and the patient’s diet, exercise and basal requirement

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2
Q

When are the greatest times of risk for hypoglycaemia?

A

Before meals, through the night and during/after exercise

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3
Q

What are some factors which may precipitate hypoglycaemia?

A

Irregular eating habits, unusual exertion and alcohol excess

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4
Q

At what BG level do symptoms of hypoglycaemia develop?

A

< 3 mmol/l

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5
Q

How quickly do symptoms of hypoglycaemia occur?

A

Over a few minutes

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6
Q

What are some adrenergic symptoms of a diabetic hypo?

A

Sweating, tremor, pounding heartbeat

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7
Q

What are some physical signs of a diabetic hypo?

A

Pallor and cold sweat

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8
Q

Which diabetic patients may report a loss of warning signs of a hypo?

A

Those with longstanding type 1

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9
Q

What are some more behavioural features of a diabetic hypo?

A

Clumsy or inappropriate, irritable or aggressive

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10
Q

What are some options to reduce the risk of an overnight hypo?

A

Having a bedtime snack // Twice daily mixed insulin // Long acting insulin analogue at night // Infusion pump

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11
Q

What is the treatment for mild hypoglycaemia?

A

A form of rapidly absorbable carbohydrate such as Lucozade

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12
Q

What should patients be treated with in severe hypoglycaemia?

A

IM glucagon (1mg) or IV glucose (25-50ml of 50%), followed by a flush of 0.9% saline

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13
Q

DKA is a disordered metabolic state which usually occurs in the context of what?

A

Relative insulin deficiency and hence increased BG

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14
Q

If insulin is decreased in DKA, what hormones are increased?

A

Counter regulatory hormones like glucagon, adrenaline, cortisol and growth hormone

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15
Q

Which type of diabetes does DKA occur in?

A

Majority type 1, but can rarely occur in type 2

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16
Q

When does DKA usually occur?

A

In times of stress e.g. infection

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17
Q

In DKA, there is a lack of insulin and so glucose cannot get into cells to be used as energy. What is used instead? By what process are these formed?

A

Fatty acids from lipolysis

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18
Q

What happens in lipolysis?

A

Triglycerides are broken down into free fatty acids and glycerol

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19
Q

After lipolysis, fatty acids are turned into what? Where?

A

Ketone bodies, in the liver

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20
Q

What is the advantage and disadvantage of the production of ketones as an energy source?

A

Advantage: they can be used by the cells for energy // Disadvantage: they increase the acidity of blood

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21
Q

When does Kussmaul’s breathing occur?

A

When the blood is very acidic (acidosis)

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22
Q

What is Kussmaul’s breathing and what is its function?

A

Deep, laboured breathing which occurs as the body tries to blow off CO2 in order to decrease acidity

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23
Q

In the cell membranes, there is a H+/K+ co-transporter. What happens to these ion concentrations in DKA?

A

Since DKA is an acidosis, there is high H+ in the blood. As a result of this, H+ is taken into cells via these transporters, meaning that K+ is transported out of cells and into the blood

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24
Q

Under normal circumstances, insulin activates the Na/K ATPase pump. What does this do?

A

K+ into cells, Na+ out of cells

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25
Q

In DKA, the Na/K ATPase pump is not activated as there is not a lot of insulin. What is the result of this?

A

K+ remains in the ECF, which quickly gets into the blood

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26
Q

Due to actions of the H+/K+ co-transporter and the Na+/K+ ATPase pump, what happens to K+ levels in DKA?

A

Rise, giving hyperkalaemia

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27
Q

What will the anion gap be in DKA?

A

High

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28
Q

Ketone bodies break down into what? When this gets released via the lungs, what does it cause?

A

Acetone // When released from the lungs this gives the breath a sweet, fruity smell

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29
Q

With regards to ketones, what must a patient have to be diagnosed as in DKA?

A

> 3mmol/l in blood (or significant ketonuria i.e. ++)

30
Q

With regards to blood glucose, what must a patient have to be diagnosed as DKA?

A

> 11mmol/l (or known diabetes)

31
Q

With regards to bicarbonate, what must a patient have to be diagnosed as DKA?

A

< 15mmol/l (or venous pH < 7.5)

32
Q

Blood ketones is the most effective way to measure ketones in DKA. What is measured when you test blood ketones?

A

Beta-Hydroxybutarate

33
Q

What is the normal range of blood ketones?

A

< 0.6mmol/l

34
Q

What is measured when you test urine ketones? Why is this not as effective a test as blood ketones?

A

Acetoacetate, this indicates the levels of ketones 2-4 hours earlier

35
Q

What can the glucose range be in DKA?

A

10-100mmol/l (usually around 40)

36
Q

What is usually the level of K+ in DKA? What do you need to be aware of?

A

> 5.5 // Must be aware of those with a low normal range, their elevated K+ may still be within the upper range of normal

37
Q

What are some other markers which are often raised in DKA?

A

Creatinine, Na+, lactate, amylase and possible WCC

38
Q

What are some common triggers of DKA?

A

Infection, drugs and alcohol, non-compliance with treatment, newly diagnosed patient

39
Q

What are signs and symptoms of DKA that are osmotic related?

A

Thirst, polyuria, dehydration

40
Q

What are some signs and symptoms of DKA that are related to the ketone bodies?

A

Flushing, vomiting, abdominal pain, dyspnoea (Kussmauls’)

41
Q

What are some complications of DKA?

A

Aspiration, VF from hyperkalaemia, sepsis, thromboembolism, cerebral oedema

42
Q

What is the commonest cause of DKA mortality in children?

A

Cerebral oedema

43
Q

What are the 3 main treatments for DKA?

A

IV fluid 0.9% NaCl, insulin and K+

44
Q

How much fluid should be given in DKA?

A

500ml bolus over 10-15 mins and then IV infusion once BP > 90

45
Q

How is K+ given in DKA?

A

Include potassium chloride in fluids

46
Q

Should established insulin therapy be continued in DKA?

A

Yes

47
Q

When should glucose be given in DKA?

A

Once BG < 14mmol/l you should give glucose 10% IV infusion

48
Q

HHS is mostly seen in which type of diabetes?

A

Type 2

49
Q

What happens to plasma osmolarity in HHS?

A

Increased (dehydration)

50
Q

In HHS, glucose in the blood is high. What does this lead to in terms of water balance?

A

Water moves out of cells to try and compensate which leads the cells shrivelled and dry

51
Q

What happens in HHS once the vessels are full of water?

A

Increased urination and dehydration

52
Q

Are ketonuria and acidosis features of HHS?

A

They can be, but not as severe as in DKA

53
Q

HHS mainly occurs in which population? What is the exception to this?

A

Mainly in the older population, only seen in young patients in non-Caucasian groups

54
Q

What has usually been taken before an episode of HHS?

A

Slowly absorbed (refined) carbohydrate

55
Q

What are some risk factors for HHS?

A

Previous CV event, sepsis, medications (especially steroids and thiazides), fizzy drinks

56
Q

What is HHS defined as?

A

Hypovolaemia and hyperglycaemia (> 50mmol/l) without significant acidosis and ketonuria

57
Q

There will usually be impairment of what body system in patients with HHS?

A

Renal

58
Q

In HHS, the value of osmolarity is often around what?

A

400mosmol/l

59
Q

How is osmolarity worked out?

A

2 (Na+ / K+) + urea + glucose

60
Q

What is the normal range of osmolarity?

A

285-295mosmol/l

61
Q

What are the main treatments for HHS?

A

Fluids and insulin, cautiously and slowly

62
Q

Rapid fluctuations in what ion should be avoided?

A

Na+

63
Q

What should patients with HHS be screened for?

A

Silent vascular event

64
Q

What medication should be given to all patients with HHS, unless it is contra-indicated?

A

LMWH

65
Q

What is lactate?

A

The end product of anaerobic metabolism of glucose

66
Q

Type A lactic acidosis is caused by what?

A

Tissue hypoxaemia

67
Q

What is type B lactic acidosis caused by?

A

Liver disease, leukaemia, diabetes

68
Q

When does lactic acidosis occur in diabetes?

A

DKA, or in severe illness/renal failure in patients on metformin

69
Q

What are some clinical findings of lactic acidosis?

A

Hyperventilation, confusion, coma

70
Q

How is lactic acidosis treated?

A

Treat the underlying condition and give fluids. Withdraw any offending medication

Endocrine- Diabetes (11 decks)

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