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MET3b > Diabetic Emergencies > Flashcards

Diabetic Emergencies Flashcards

1
Q

When do hypoglycaemic symptoms typically occur?

A

Glucose - 3.6mmol/L

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2
Q

What is false hypoglycaemia?

A
  • patients with consistently high glucose levels experience hypo at higher level than someone with good glycaemic control
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3
Q

Causes of hypoglycaemia

A
  • imbalance between carb and insulin or sulfonylurea therapy
  • exercise with too much insulin or not enough carbs
  • alcohol (even in non-diabetics)
  • vomiting
  • breastfeeding
  • other medical causes
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4
Q

Other medical causes of hypoglycaemia

A
  • liver disease
  • progressive renal impairment
  • hypoadrenalism
  • hypothyroidism
  • hypopituitarism (rare)
  • insulinoma (rare)
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5
Q

Autonomic symptoms of hypoglycaemia

A
  • sweating
  • shaking/tremor
  • anxiety
  • palpitations
  • hunger
  • nausea
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6
Q

Neuroglycopenic symptoms

A
  • confusion
  • slurred speech
  • visual disturbances
  • drowsiness
  • aggression
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7
Q

Define neuroglycopenia

A

When glucose reaches 2.7mmol/L

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8
Q

What is hypoglycaemia unawareness?

A
  • loss of early warning signs
  • increased risk of having severe hypo
  • associated with increased risk of death/road traffic accidents
  • caused by increased duration of diabetes, tight glycaemic control, autonomic neuropathy
  • reverse by hypo - holiday
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9
Q

What is hypo holiday?

A
  • strict hypoglycaemia avoidance
  • relax glycaemic control
  • use analogue insulin
  • continuous subcutaneous insulin infusion
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10
Q

Hypoglycaemia Stages

A 
MILD = conscious, can self treat
MODERATE = conscious, cannot self administer and need help
SEVERE = unconscious
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11
Q

Mild hypoglycaemia treatment

A
  • sugary drink (coke, OJ, Lucozade)
  • 5-7 glucose tablets
  • 3-4 heaped teaspoons of sugar in water
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12
Q

Moderate hypoglycaemia treatment

A
  • glucogel/jam/honey/treacle massage into cheek

- IM glucagon

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13
Q

Severe hypoglycaemia treatment

A
  • do not put anything in mouth
  • recovery position
  • 0.5-1mg glucagon IM
  • call 999 is unable to administer glucagon
  • in hospital = IV glucose
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14
Q

What is the IV glucose dose in hospital?

A
  • 75ml of 20% glucose over 15 mins OR
  • 150mls of 10% glucose over 15 mins
  • 50mls of 50% can be given but be careful with veins as extravasation can cause chemical burns
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15
Q

Post hypo treatment

A
  • once glucose above 4mmol/L

- long acting carbs needed = slice of toast, 2 biscuits, milk 200-300ml, normal meal if due containing carbs

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16
Q

Hypoglycaemia and driving

A
  • insulin use does not prohibit
  • advice = plan in advance, carbs in car, check glucose before driving and every 2 hours, first sign of hypo stop as soon as safe, leave driver seat and remove key, do not drive again until full recovery
  • DVLA inform and insurance company
  • if 1 or more severe hypo licence revoked requiring 3rd party assistance
17
Q

Nocturnal hypo when

A
  • if patient wakes up with high blood glucose, headaches
  • confirm by testing blood glucose levels during night 3am or continuous glucose monitoring sensor over 5 days subcutaneously
18
Q

Management of nocturnal hypo

A
  • analogue insulins
  • pre bed snack
  • change timing of insulin
  • insulin pump therapy
19
Q

Define DKA

A
  • state of absolute or relative insulin deficiency resulting in hyperglycaemia and accumulating of ketoacids in blood with subsequent metabolic acidosis
20
Q

3 requirements/defining factors of DKA

A
  • hyperglycaemia so >14mmol/L
  • acidosis so ph<7.3 and bicarb <15mmol/L
  • elevated serum or urine ketones
21
Q

Pathogenesis of DKA

A
  • insulin deficiency inhibiting gluconeogenesis
  • catecholamines in excess promote lipolysis and stimulate gluconeogenesis
  • FFA metabolism = ketosis
  • ketone bodies accumulate (3-OH-butyric acid and acetoacetic acid) = acidosis
  • insulin terminates ketosis
22
Q

Clinical features of DKA

A
  • abdominal pain
  • vomiting
  • Kussmaul’s respiration (deep sighing respirations)
  • ketones on breath
  • drowsiness/confusion
  • dehydration
  • tachycardia
23
Q

What fluids and electrolytes are lost in DKA?

A
  • water 6-8L
  • sodium 0.5-1L
  • chloride 350mmol
  • potassium 0.5-1L
  • calcium 50-100mmol
  • Ph 50-100mmol
  • Mg 25-50mmol
24
Q

Precipitating factors of DKA

A
  • insulin omission
  • infection
  • pregnancy
  • MI
  • intoxication/drugs
  • unknown 40%
25
Q

Diagnosis of DKA

A
  • venous blood gas for acidosis and bicarb
  • capillary blood glucose (can be lower than 14mmol/L if alcohol ketosis or euglycaemic ketosis)
  • frequently raised urea and creatinine
  • raised urine or plasma ketones
26
Q

Investigations in DKA

A
  • pregnancy test
  • ECG/CXR
  • MSU/blood cultures
  • biochemical profile/lab glucose
  • FBC
  • HBA1c
27
Q

What suggests greater severity of DKA?

A
  • blood ketones >6mmol/L
  • bicarb <5mmol/K
  • pH < 7.1
  • potassium <3.5mmol/L
  • GCS <12 (Glasgow)
  • O2 sats <92%
  • systolic BP <90mmHg
  • pulse >100 or <60
28
Q

Monitoring/supportive management for DKA

A
  • level 2 bed (high dependency unit)
  • cardiac monitor
  • nasogastric tube if impaired conscious level
  • central venous pressure line (esp in elderly)
  • oxygen if PaO2 <10.5kPa
  • urinary catheter
  • prophylactic LMW heparin
  • IV AB if infection suspected
  • monitor conscious level, BP, pulse, temp, glucose, urine output, potassium and acidosis frequently
29
Q

Fluid therapy for DKA

A

NaCl = 0.9%
- 1L immediately
- next hour 1L
- 2hr 1L + 20mmol KCl
- 4hr 1L + KCl
- 4hr 1L + KCl
5 or 10% glucose
- when CBG < 12mmol/L and continue at 125ml/hr
- 10% glucose to increase insulin infusion
- if glucose falls below 6mmol/L increase infusion rate

30
Q

Protocol of giving potassium in fludis for DKA

A
  • first 1-2 bags in fluid no potassium as fluid given is too rapid
  • using bag of fluid containing KCl for every subsequent bag of NaCl 0.9% or glucose 5%
    if serum potassium is ≤ 5.5
  • if serum K+ 3.5-5.5 20-40mmol/Luse
31
Q

Protocol of giving insulin in DKA

A
  • continue long acting on admission if diabetic
  • commence insulin infusion by IV syringe pump
  • fixed rate IV insulin infusion (0.1U/kg = 6-8U/hr for most patients, to achieve bicarb rise of 3 mmol/hr, if not achieved increase rate by 1U/hour)
32
Q

Significance of cerebral oedema in DKA

A
  • commonest cause of death from DKA in children
  • dexamethasone or mannitol
  • high mortality
33
Q

DKA recovery

A
  • usual subcutaneous insulin once eating and drinking reliably
  • nausea and unable to eat normally until ketones clear
  • persisting ketonuria if lack of adequate glucose and insulin admin
  • self care and sick day rule education to prevent future DKA
34
Q

What is hyperosmolar hyperglycemic syndrome

A
  • T2D
  • longer subacute history
  • > 40mmol/L hyperglycemia
  • osmolality >340, hypernatremia
  • ketonuria may have
  • no ketoacidosis but may have lactic acidosis
  • severe dehydration
35
Q

HHS treatment

A
  • IV fluids like DKA
  • consider slower fluids if elderly/HF
  • no insulin bolus
  • much lower dose insulin and maybe none for first 12 hours then low doses (1U/hr)
  • avoid rapid shifts in glucose as risk of rapid fluid/sodium shifts = central pontine myelinolysis
  • monitor CVP?
  • K+ tends to decline rapidly
  • LMWH to reduce thrombosis
  • correct BG at max 2mmol/L/hr
  • biochem will be abnormal for days or risk hypernatremia, CPM, cerebral oedema
36
Q

Sick day rules

A

If on insulin and ill

  • drink fluids!!
  • if unable to eat drink sugary fluids
  • monitor glucose levels more regularly
  • never stop tablets or insulin
  • insulin may need to be increased as stressed
  • if take oral agents may need insulin for duration of illness
  • if unable to keep fluids down come straight to hospital

MET3b (20 decks)

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