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Diabetic Emergencies Flashcards

1
Q

When can you get DKA

A

Presentation type 1 = 80%
Complication existing type 1 if no insulin = 80%
Can occur in extreme stress in type 2 / MODY but unlikely
- More likely HHS

Never in non-diabetic

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2
Q

What causes DKA and what is the triad

A

Body stores believe there is no glucose as not taken up due to lack of insulin
Uncontrolled lipolysis results in extra free FA
Converted to ketone bodies
Usually high glucose + fluid deplete due to osmotic diuresis

Ketoacidosis
Dehydration - extreme fluid deficit up to 10l
Hyperglycaemia
K imbalance

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3
Q

What are precipitating factors

A 
Know type 1
Infection / stress due to increased countergulatory hormones e.g. cortisol 
- Infection = most common 
- Electrolyte imbalance 
- Silent MI
- PE 
- Ischaemic bowel 
- Stroke 
Fluid deplete
Missed insulin dose
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4
Q

What should you do if unwell or BG >14

A

Check ketones

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5
Q

If ketones <1.4 what do you do

A

Have sugar free fluid
Correct insulin
Recheck levels

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6
Q

What do you do if ketones <2.9

A

Contact DM tean

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7
Q

If ketones >3 what do you do

A

Urgent medical advice

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8
Q

What are features of DKA

A 
Abdo pain 
- due to hypovolaemia and bowel ischaemia 
Polyuria and polydipsia
N+V
Weakness
Confusion 
Signs 
Dehydration
Increased RR + HR
Low BP - hypotension 
Kausmall resp - deep hypventilation in response to metabolic acidosis 
Acetone smelling breath
Hypothermia
Altered mental state / lethargy 
Coma
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9
Q

How do you Dx DKA

A

Glucose >11
pH <7.3
Bicarb <15
Ketones >3 or +ve on dip

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10
Q

When do you involve consultant

A

Hypokalaemia - lost in diuresis as not taken into cells (insulin drives in)
Reduced consciousness
Cerebral oedema
Severe DKA

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11
Q

When is DKA severe and what should you do

A

pH <7.1
HCO3 <5
Involve ICU early if pH <7.1
Call up

Mild <7.3
Mod <7.2

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12
Q

What do you do initially

A 
ABCDE
IV access
- Can be difficult as peripherally shut down 
- ITU if no access or extreme acidosis 
Vital signs
Glucose
VBG
Urinanalysis 
Bloods - FBC, U+E, LFT, CRP 
Blood and urine culture
ECG
Consider CXR
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13
Q

How do you Rx if shock and no shock

A

If shock / reduced pulse vol / reduced GCS

  • ABCDE
  • Airway +- NG
  • O2 100%
  • Bolus 20ml / kg (sometimes 10ml/kg due to risk of cerebral oedema in kids) or 500ml in adult / 250 if HF

If no signs of shock

  • IV fluid lots
  • IV insulin

Fluid replacement - isotonic saline initially
Usually one bag over one hour then another bag over 2 hours but look hospital guidelines
Insulin 0.1 unit / kg / hour to drive glucose and K into cells (stops process of ketogenesis) - ALWAYS FIXED RATE (mixed with saline)
Check ketones and BG hourly and VBG regular
Ketones >0.5 / hour and BG >3
Correct hypokalaemia
Continue long acting insulin but stop short acting
Continue fixed rate insulin till ketones <0.3, pH >7.3 and patient able to eat and drink

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14
Q

When do you start dextrose infusion

A

When BG falls to <15 to prevent hypoglycaemia
Runs alongside saline
10% glucose unit at 125ml / hour along with saline

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15
Q

How do you correct hypokalaemia

A

Insulin will help as drives K into cells (serum K often high as insulin deplete in DKA but total K low due to dehydration and loses) - careful monitoring
If K >5.5 = no K added
Add KCL if K <5.5
Get specialist advise if <3.5

Slow infusion to avoid arrthymia
- Usually no more than 10mmol / hour but exception here when 40mmol into bag

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16
Q

What else should you consider

A

DVT prophylaixs - start all on LMWH due to inflammatory process
NG tube if vomiting or drowsy
Catheter and monitor urine output if no urine by one hour
Central line
Monitor K, fluid balance, ketones, glucose, PH REGULAR

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17
Q

What are risks of DKA

A 
Cerebral oedema due to Rx 
- Huge risk in paeds
- Due to being dehydrated and rapidly correction forcing fluid into brain cells 
Gastric stasis
VTE
Arrhythmia due to K
ARDS 
AKI
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18
Q

What are signs of cerebral oedema

A 
4-12 hours after Rx 
Headache
Irritable
Visual disturbance
Focal neuro
Bradycardai 
Often wait 1 hour after fluid before give insulin in children to prevent
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19
Q

How do you Dx and RX

A 
Regular review - pads get GCS tested every 1 hour 
Head CT
Senior review
Slow fluids
IV mannitol 
IV hypertonic saline
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20
Q

What should you do if unwell

A

Never stop insulin
BG monitoring + ketone testing
May need extra doses
Regular CHO even if BG high

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21
Q

What causes hypoglycaemia in diabetic

A

Too much insulin or bad timing or injection site problem
Oral hypoglycaemics - sulphonurea
Inadequate food
Exercise / increased activity
Alcohol - impairs release of glucose from liver
Malabsorption / vomiting / diarrhoea

Othr causes - non DM

  • Insulinoma
  • Addisons
  • Hypothyroid
  • Liver fiailure
  • Drugs
  • Pituitary insufficiency - GH
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22
Q

Who is at risk of hypoglycaemia

A 
Tight control
Impaired awareness
Age extremes
Abrupt steroid withdrawal / hypoadrenalism 
Malabsorption / coeliac
Renal / hepatic impairment
Pregnancy
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23
Q

What causes impaired awareness (no symptoms but still need treated if BG <4)

A 
Neuropathy = most common
Recurrent hypoglycaemia
Long duration
Overtight control
Loss of sweating or tremor
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24
Q

What does hypoglycaemia cause

Autonomic Sx
Neuro Sx
General

A 
Headache
Nausea
Sweating
Palpitations
Shaking
Hunger
Sweating 
Irritable 
Confusion / drowsy
Dizzy 
Visual disturbance 
Odd behaviour
Speech difficulty
- Can appear like stroke 
Incoordination
Seizure 
Coma 
Brain damage and death
25
How do you manage if mild
``` ABCDE Grab hypo box 15-20g simple quick acting CHO Recheck BG after 10 minutes Repeat up to 3 times Follow up with long acting CHO as will go into hypo quickly (if no stores or insulin still in blood) ```
26
If unable to take CHO (classed as severe)
2 tube glucogel if conscious but poor swallow Always put a line in, incase don't improve and need access 1mg IM glucagon ONCE - Impotant to remember won't work if no glycogen store in liver e.g. alcohol / malnourished Urgent help
27
How do you Rx in hospital
IV dextrose as per protocol (10/20% in 150ml then reassess after 10 minutes) - Aim for big vein as risk of thrombophlebitis 1mg IM glucagon only If can't get access If no access end up in ITU for central line so always phone up
28
If ar risk of hypo what should you have
``` Hypobox Fruit juice Glucogel 50% dextrose Hypo management protocol ```
29
What should you do after attack
``` Once BG >4 go back to taking insulin when due Find out why - NBM ? - Check renal as increases insulin - Check food chart Discuss driving work Injection sites Advise about food / activity ```
30
How do you avoid hypo
Regular monitoring Rotate injection Regular carb counting
31
If driving
Check BG before and every 2 hours Carry CHO No more than 1+ hypo in a year
32
What is body's response to hypo
Decreased insulin Increased glucagon GH + cortisol release
33
What is hyperosmolar hyperglycaemic state and what causes
``` Medical emergency where prolonged hyperglycaemia causes Osmotic diuresis Severe dehydration + increased serum osmolarity Renal failure Electrolyte deficiency Na usually elevated but can be normal Elevated urea as intravascular dry No ketones ``` Usually occurs with - Intercurrent illness - Diuretics - Large sugary drinks
34
Why may not appear dehydrated
Hypertonicity preserves intravascular volume
35
Who typically presents
Elderly | Type II UnDx
36
What are features
``` Fatigue Lethargy N+V Altered consciousness Papilloedema Weakness Hyperviscosity Dehydration Hypotension Tachycardia ```
37
What is important to do
Differentiate from DKA
38
What are complications
``` Pressure ulcer VTE - Big risk due to thick sugary syrup MI Stroke PAD Seziure Cerebral oedema Central pontine myelinolysis ```
39
How do you Dx
Hypovolaemia Marked hyperglycaemia + no ketones Raised serum osmolarity >320 If not dehydrated + Na / urea normal then unlikely
40
How do you Rx
``` As per trust protocol Normalise osmolality Replace fluid and electrolyte IV fluid 0.9% saline Normalise BG Sometimes use insulin if ketotic or difficulty getting down ```
41
What is given as fluid replacement
IV NaCL as hypotonic Measure serum osmolarity, Na and glucose to see rate of change Slow to prevent oedema
42
Caution
Elderly HF CKD
43
What else do you give
Insulin - rapid decline in glucose and osmolarity (variable rate NOT fixed rat) K - either replace or omit as required Prophylactic anti-coagulation as high risk of thrombosis
44
What kills in DKA
Acidosis from ketones or renal failure Severe dehydration or electrolyte disturbance - K Impaired consciousness due to raised osmolality or ketones
45
What does kidney do try and correct DKA
Produce bicarb but eventually store runs out and become acidotic If bicarb low = life threatening
46
What causes signs of DKA
``` Hyperglycaemia filtered into urine Draws out water = osmotic diuresis Produce polyuria Severe dehydration Stimulates thirst = polydipsia ```
47
How is K affected
Insulin drives K into cells If no insulin then can't go into cell In DKA total K is low as none stored in cells and washed out When start insulin risk of hypokalaemia as taken back up into cells
48
How fast should K be corrected
No more than 10mmol / hour
49
If hyperglycaemia but no ketones
May need extra insulin | 1 unit RA reduce insulin by 4mmol
50
What causes cerebral oedema
If dehydration / high sugar water will move out of cells into extracellular space Brain cells shrink and become dehydrated Rapid correction leads to brain cells swelling and becoming oedematous Can lead to brain destruction and death
51
How often do you check BG and ketones in DKA and what should it decrease by
Check hourly Ketones >0.5 / hour Glucose >3 / hour
52
What else should you do in DKA
Check VBG regular | Check potassium
53
When do you stop fixed rate insulin
Ketones <0.3 pH >7.3 Patient can eat and drink
54
DDK of hypo / what can mimc
``` DKA Substance withdrawal / alcohol Stroke - Slurred speech etc so always check Seizures Reduced GCS ```
55
What should anyone with reduced GCS get
Blood glucose
56
What is euglycaemic DKA
``` If on SGLT-2 inhibitor Due to glucose diuresis caused by drugs High ketones Acidosis Normal glucose ```
57
Diff hypo and hyper
Hypo - More acute - Too much insulin / not enough food DKA - Been unwell
58
If having hypo
Reduce insulin dose by 20% | Give long acting CHO
59
What do you never do
Stop insulin as can lead to DKA

Endocrine (17 decks)

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