Diabetic Emergencies

Question 1

Pathogenesis of DKA

Answer 1

↓ Insulin:
Ketogenesis
Dehydration
Acidosis

Question 2

Ketogenesis in DKA

Answer 2

↓ Insulin
↑ fatty acids
→ ↑ ATP + generation of ketone bodies

Question 3

Dehydration in DKA

Answer 3

↓ Insulin
↑ GNG
Osmotic diuresis → dehydration
Also, ↑ ketones → vomiting

Question 4

Acidosis in DKA

Answer 4

Dehydration → ↓ renal perfusion
Hyperkalaemia

K and H exchange

Question 5

Precipitants of DKA

Answer 5

Infection / stress
+/- Stopping insulin
New T1DM

Question 6

Presentation of DKA

Answer 6

Abdo pain
Vomiting
Gradual drowsiness
Sighing “Kussmaul” hyperventilation
Dehydration
Ketotic breath

Question 7

Diagnosis of DKA

Answer 7

Acidosis
Hyperglycaemia > 11 mM (or known DM)
Ketonaemia > 3 mM (> 2 on dipstick)

Question 8

Ix for DKA

Answer 8

Urine - ketones + glucose
Cap - ketones + glucose
VBG - acidosis, ↑K
Bloods
CXR - ?infection
Amylase often raised

Question 9

Complications of DKA

Answer 9

Cerebral oedema
Aspiration pneumonia
Hypokalaemia
Hypophosphataemia
Thromboembolism

Question 10

Mx of DKA

Answer 10

GRIP

Gastric aspiration
Rehydrate
Insulin infusion
Potassium replacement

Remove ketones

Question 11

Insulin infusion for DKA dose

Answer 11

Actrapid
0.1 u/kg/hr IV
6u if no wt
Max 15u

Question 12

Resolution of DKA

Answer 12

Ketones < 0.3 mM

+ venous pH > 7.3

Question 13

HHS

Answer 13

Hyperosmolar Hyperglycaemic State

Question 14

Patient demographic of HHS

Answer 14

T2DM
Older
Long history (eg. 1 wk)

Question 15

Pathophysiology of HHS

Answer 15

Dehydration
Hyperglycaemia > 35 mM
Osmolality > 340 mosmol/kg
No acidosis (no ketogenesis)

Question 16

Complications of HHS

Answer 16

Occlusive events - DVT, Stroke

Give LMWH

Question 17

Mx of HHS

Answer 17

Saline over 48 hrs - may need 9L
Wait 1 hr before starting insulin
Look for precipitant

Question 18

Why wait 1 hr to start insulin for HHS?

Answer 18

May not be needed

Start slow

Question 19

Precipitants to HHS

Answer 19

MI

Infection

Bowel infarct

Question 20

Whipple’s Triad

Answer 20

Hypoglycaemia < 3 mM
Symptoms of hypoglycaema
Relief of Sx by glucose administration

Question 21

Symptom categories of hypoglycaemia

Answer 21

Autonomic 2.5-3 mM
Neuroglycopenic < 2.5 mM

Question 22

Autonomic symptoms of hypoglycaemia

Answer 22

Sweating
Anxiety
Hunger
Tremor
Palpitations

Question 23

Neuroglycopenic symptoms of hypoglycaemia

Answer 23

Confusion
Drowsiness
Seizures
Focal neurology (eg. CN3)
Coma

Question 24

Glucose level of coma

Answer 24

< 2.2

Question 25

Causes of fasting hypoglycaemia

Answer 25

I EXPLAIN

Islet cell tumours (insulinomas)
EXogenous drugs
Pituitary insufficiency
Liver failure
Addison’s
Immune (insulin receptor Abs)
Non pancreatic neoplasms

Question 26

Ix for asymptomatic fasting hypoglycaemia

Answer 26

72 hr fast with monitoring

Question 27

Ix for symptomatic fasting hypoglycaemia

Answer 27

Glucose

Insulin

C-peptide

Ketones

Question 28

Diagnoses of hyperinsulinaemic hypoglycaemia

Answer 28

Exogenous drugs

Insulinoma

Question 29

Ix of hyperinsulinaemic hypoglycaemia

Answer 29

• ↑ C-pep: sulfonylurea
• Normal C-pep: insulin

Question 30

Diagnoses of hypoglycaemia with ↓ insulin, ↑ ketones

Answer 30

EtOH binge w/o food
Pituitary insufficiency
Addison’s

Question 31

Diagnoses of hypoglycaemia with ↓ insulin, no ketones

Answer 31

Non pancreatic neoplasms
Immune

Question 32

Modes of glucose administration

Answer 32

Food / lucozade
Buccal Glucogel
IV dextrose