Diabetic emergencies

Question 1

What is the mechanism by which diabetic ketoacidosis develops?

Answer 1

In normal state the body metabolises carbohydrates to efficiently produce energy. If there is not enough insulin then ketoacidosis can develop because the glucose is not being moved into the cells. This means that the body is pushed into the starvation ketoacidosis state where carbohydrates are metabolised by an alternative pathway. This causes production of acetone (fruity breath in ketosis). This combination of severe acidosis and hyperglycaemia can be deadly

Question 2

What is the typical presentation of diabetic ketoacidosis?

Answer 2

Gradual drowsiness
Vomiting
Abdo pain
Dehydration
Always do glucose

Question 3

What are the triggers of diabetic ketoacidosis?

Answer 3

THe triggers are:

• Infection
• Surgery
• MI
• Pancreatitis
• chemotherapy
• Antipsychotics

Question 4

How is a diagnosis of DKA made?

Answer 4

Acidaemia (venous blood pH <7.3
Hyperglycaemia (blood glucose >11.1mmol/L) or known DM
Ketonaemia (>3mmol/L)

Question 5

What are the criteria for serious DKA and consideration for HDU?

Answer 5

Blood ketones >6mmol/L
Venous pH<7
GCS <12
O2 sats <92%

Question 6

What is the management of diabetic ketoacidosis?

Answer 6

A-E approach
2 large bore cannulae
Start fluid 1L 0.9% saline over 1 hr
Perform blood tests e.g. venous blood gas for pH and bicarb, glucose and ketones
Add 50 units insulin to 50mL 0.9% saline
Infuse at 0.1unit/kg/hr
Chek capillary blood glucose and ketones hourly
Continue fluids and assess need for K+
Avoid hypoglycaemia, when glucose reaches <14mmol/L start 10% glucose infusion
Find and treat cause of DKA

Question 7

Why does K+ fall during DKA treatment?

Answer 7

Insulin causes K+ to be taken up into cells

Question 8

What are some of the complications of diabetic ketaacidosis?

Answer 8

Cerebral oedema
Aspiration pneumonia
hypokalaemia
hypophosphataemia

Question 9

What are some of the clinical features of hypoglycaemia?

Answer 9

It is usually rapid onset and accompained by odd behaviour:

• Sweating
• Increased pulse
• seizures

Question 10

What is the management of hypoglycaemia?

Answer 10

If conscious, orientated and able to swallow give 15-20g of quick-acting carbohydrate
Check blood glucose after 10-15 mins
If conscious but uncooperative then squirt glucose between teeth and gums
If unconscious then give 20% IVI glucose or give glucagon 1mg IV
Once glucose >4.0mmol/L give long acting carbohydrate e.g. toast

Question 11

What is hyperglycaemic hyperosmolar state?

Answer 11

This develops over a longer period of time (1wk) in patients with type 2 diabetes
There is marked dehydration and glucose >30mmol/L
No switch to ketone metabolism

Question 12

What is the management of hyperglycaemic hyperosmolar state?

Answer 12

Occlusive events are a danger so give LMWH unless contraindicated
Rehydrate slowly with 0.9% saline IVI over 48 hours
Replace K+ when urine starts to dlow
Only use insulin if blood glucose not falling by 5mmol/L/h with rehydration