Diabetic Emergencies

Question 1

Why does hypoglycaemia occur?

Answer 1

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

Question 2

When are the greatest times of risk for hypoglycaemia?

Answer 2

Before meals, through the night and during/after exercise

Question 3

What are some factors which may precipitate hypoglycaemia?

Answer 3

Irregular eating habits, unusual exertion and alcohol excess

Question 4

At what BG level do symptoms of hypoglycaemia develop?

Answer 4

< 3 mmol/l

Question 5

How quickly do symptoms of hypoglycaemia occur?

Answer 5

Over a few minutes

Question 6

What are some adrenergic symptoms of a diabetic hypo?

Answer 6

Sweating, tremor, pounding heartbeat

Question 7

What are some physical signs of a diabetic hypo?

Answer 7

Pallor and cold sweat

Question 8

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

Answer 8

Those with longstanding type 1

Question 9

What are some more behavioural features of a diabetic hypo?

Answer 9

Clumsy or inappropriate, irritable or aggressive

Question 10

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

Answer 10

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

Question 11

What is the treatment for mild hypoglycaemia?

Answer 11

A form of rapidly absorbable carbohydrate such as Lucozade

Question 12

What should patients be treated with in severe hypoglycaemia?

Answer 12

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

Question 13

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

Answer 13

Relative insulin deficiency and hence increased BG

Question 14

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

Answer 14

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

Question 15

Which type of diabetes does DKA occur in?

Answer 15

Majority type 1, but can rarely occur in type 2

Question 16

When does DKA usually occur?

Answer 16

In times of stress e.g. infection

Question 17

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?

Answer 17

Fatty acids from lipolysis

Question 18

What happens in lipolysis?

Answer 18

Triglycerides are broken down into free fatty acids and glycerol

Question 19

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

Answer 19

Ketone bodies, in the liver

Question 20

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

Answer 20

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

Question 21

When does Kussmaul’s breathing occur?

Answer 21

When the blood is very acidic (acidosis)

Question 22

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

Answer 22

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

Question 23

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

Answer 23

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

Question 24

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

Answer 24

K+ into cells, Na+ out of cells

Question 25

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

Answer 25

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

Question 26

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

Answer 26

Rise, giving hyperkalaemia

Question 27

What will the anion gap be in DKA?

Answer 27

High

Question 28

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

Answer 28

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

Question 29

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

Answer 29

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

Question 30

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

Answer 30

> 11mmol/l (or known diabetes)

Question 31

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

Answer 31

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

Question 32

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

Answer 32

Beta-Hydroxybutarate

Question 33

What is the normal range of blood ketones?

Answer 33

< 0.6mmol/l

Question 34

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

Answer 34

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

Question 35

What can the glucose range be in DKA?

Answer 35

10-100mmol/l (usually around 40)

Question 36

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

Answer 36

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

Question 37

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

Answer 37

Creatinine, Na+, lactate, amylase and possible WCC

Question 38

What are some common triggers of DKA?

Answer 38

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

Question 39

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

Answer 39

Thirst, polyuria, dehydration

Question 40

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

Answer 40

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

Question 41

What are some complications of DKA?

Answer 41

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

Question 42

What is the commonest cause of DKA mortality in children?

Answer 42

Cerebral oedema

Question 43

What are the 3 main treatments for DKA?

Answer 43

IV fluid 0.9% NaCl, insulin and K+

Question 44

How much fluid should be given in DKA?

Answer 44

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

Question 45

How is K+ given in DKA?

Answer 45

Include potassium chloride in fluids

Question 46

Should established insulin therapy be continued in DKA?

Answer 46

Yes

Question 47

When should glucose be given in DKA?

Answer 47

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

Question 48

HHS is mostly seen in which type of diabetes?

Answer 48

Type 2

Question 49

What happens to plasma osmolarity in HHS?

Answer 49

Increased (dehydration)

Question 50

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

Answer 50

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

Question 51

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

Answer 51

Increased urination and dehydration

Question 52

Are ketonuria and acidosis features of HHS?

Answer 52

They can be, but not as severe as in DKA

Question 53

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

Answer 53

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

Question 54

What has usually been taken before an episode of HHS?

Answer 54

Slowly absorbed (refined) carbohydrate

Question 55

What are some risk factors for HHS?

Answer 55

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

Question 56

What is HHS defined as?

Answer 56

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

Question 57

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

Answer 57

Renal

Question 58

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

Answer 58

400mosmol/l

Question 59

How is osmolarity worked out?

Answer 59

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

Question 60

What is the normal range of osmolarity?

Answer 60

285-295mosmol/l

Question 61

What are the main treatments for HHS?

Answer 61

Fluids and insulin, cautiously and slowly

Question 62

Rapid fluctuations in what ion should be avoided?

Answer 62

Na+

Question 63

What should patients with HHS be screened for?

Answer 63

Silent vascular event

Question 64

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

Answer 64

LMWH

Question 65

What is lactate?

Answer 65

The end product of anaerobic metabolism of glucose

Question 66

Type A lactic acidosis is caused by what?

Answer 66

Tissue hypoxaemia

Question 67

What is type B lactic acidosis caused by?

Answer 67

Liver disease, leukaemia, diabetes

Question 68

When does lactic acidosis occur in diabetes?

Answer 68

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

Question 69

What are some clinical findings of lactic acidosis?

Answer 69

Hyperventilation, confusion, coma

Question 70

How is lactic acidosis treated?

Answer 70

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