Diabetic emergencies

Question 1

ABCDE approach (DKA)

Answer 1

Confirm diagnosis:
Glucose > 11 mmol/L or known diabetes
pH < 7.3 or HCO3 < 15
Capillary ketones > 3 mmol/L or ++ urinary ketones

Question 2

IV fluids (DKA)

Answer 2

1L saline over 1 hour (faster if hypotensive) - without potassium 
1L saline over 2 hours
1L saline over 2 hours
1L saline over 4 hours
1L saline over 4 hours
1L saline over 6 hours
1L saline over 6 hours

After 1st liter add potassium chloride depending on VBG results (< 4.5 = 40, 4.5-5.5 = 20, > 5.5. = 0)

Question 3

Fixed rate insulin infusion (DKA)

Answer 3

IV insulin infusion 0.1 unit / kg / hour from 50 units human soluble rapid-acting insulin in 50 mL normal saline

When glucose < 14 mmol/L give 10% IV glucose at 125mL / hour in addition to the normal saline but reduce saline rate to account for extra fluid

Question 4

Investigate to find cause (DKA)

Answer 4

Hx
Full examination 
Bloods (FBC, glucose, U&Es, LFTs, osmolality, CRP)
Blood culture
MSU
CXR

Question 5

Target (DKA)

Answer 5

Aim to:
Increase HCO3 by 3 mmol / hour
Reduce glucose by 3 mmol / hour
Reduce ketones by 0.5 mmol / L / hour

Question 6

Hyperosmolar hyperglycaemic state

Answer 6

Confirm dx: marked hyperglycaemia (>/ 30) without ketosis, serum osmolality >/ 320, hypovolaemia

Rehydrate with normal saline (same rate as DKA), VTEprophylaxis, start IV insulin infusion at 0.05 units / kg / hour if glucose not falling with fluids alone, look for cause, hold metformin for 2 days (causes a metabolic acidosis)

Question 7

Hyperglycaemia without DKA

Answer 7

Rehydrate if necessary 
STAT dose of rapid-acting or short-acting insulin (type 1 - 1 unit decreass blood glucose by 3 mmol/L, type 2 0.1 unit / kg)
Identify and correct cause
Adjust normal insulin as necessary 
Recheck glucose in 1 hour and reassess

Question 8

Hypoglycaemia

Answer 8

Unconscious - 150mL glucose or 75mL glucosw IV STAT, glucagon 1mg UM or no IV access, check capillary glucose 10 mins later, long acting carb when able to swallow

Conscious but cannot swallow - 1.5-2 tubes glucose gel around teeth if mild, check BM 10 mins later and give long acting carb when able to swallow

Can swallow - 15-30g fast acting carb and long acting carb