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Endocrine > Diabetic Emergencies > Flashcards

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
Q

How do you manage if mild

A 
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
Q

If unable to take CHO (classed as severe)

A

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
Q

How do you Rx in hospital

A

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
Q

If ar risk of hypo what should you have

A 
Hypobox
Fruit juice
Glucogel 
50% dextrose
Hypo management protocol
29
Q

What should you do after attack

A 
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
Q

How do you avoid hypo

A

Regular monitoring
Rotate injection
Regular carb counting

31
Q

If driving

A

Check BG before and every 2 hours
Carry CHO
No more than 1+ hypo in a year

32
Q

What is body’s response to hypo

A

Decreased insulin
Increased glucagon
GH + cortisol release

33
Q

What is hyperosmolar hyperglycaemic state and what causes

A 
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
Q

Why may not appear dehydrated

A

Hypertonicity preserves intravascular volume

35
Q

Who typically presents

A

Elderly

Type II UnDx

36
Q

What are features

A 
Fatigue 
Lethargy 
N+V
Altered consciousness 
Papilloedema
Weakness
Hyperviscosity
Dehydration
Hypotension
Tachycardia
37
Q

What is important to do

A

Differentiate from DKA

38
Q

What are complications

A 
Pressure ulcer 
VTE 
- Big risk due to thick sugary syrup 
MI
Stroke
PAD 
Seziure
Cerebral oedema
Central pontine myelinolysis
39
Q

How do you Dx

A

Hypovolaemia
Marked hyperglycaemia + no ketones
Raised serum osmolarity >320

If not dehydrated + Na / urea normal then unlikely

40
Q

How do you Rx

A 
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
Q

What is given as fluid replacement

A

IV NaCL as hypotonic
Measure serum osmolarity, Na and glucose to see rate of change
Slow to prevent oedema

42
Q

Caution

A

Elderly
HF
CKD

43
Q

What else do you give

A

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
Q

What kills in DKA

A

Acidosis from ketones or renal failure
Severe dehydration or electrolyte disturbance - K
Impaired consciousness due to raised osmolality or ketones

45
Q

What does kidney do try and correct DKA

A

Produce bicarb but eventually store runs out and become acidotic
If bicarb low = life threatening

46
Q

What causes signs of DKA

A 
Hyperglycaemia filtered into urine
Draws out water = osmotic diuresis
Produce polyuria 
Severe dehydration
Stimulates thirst = polydipsia
47
Q

How is K affected

A

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
Q

How fast should K be corrected

A

No more than 10mmol / hour

49
Q

If hyperglycaemia but no ketones

A

May need extra insulin

1 unit RA reduce insulin by 4mmol

50
Q

What causes cerebral oedema

A

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
Q

How often do you check BG and ketones in DKA and what should it decrease by

A

Check hourly
Ketones >0.5 / hour
Glucose >3 / hour

52
Q

What else should you do in DKA

A

Check VBG regular

Check potassium

53
Q

When do you stop fixed rate insulin

A

Ketones <0.3
pH >7.3
Patient can eat and drink

54
Q

DDK of hypo / what can mimc

A 
DKA
Substance withdrawal / alcohol 
Stroke 
- Slurred speech etc so always check 
Seizures 
Reduced GCS
55
Q

What should anyone with reduced GCS get

A

Blood glucose

56
Q

What is euglycaemic DKA

A 
If on SGLT-2 inhibitor 
Due to glucose diuresis caused by drugs 
High ketones
Acidosis
Normal glucose
57
Q

Diff hypo and hyper

A

Hypo

  • More acute
  • Too much insulin / not enough food

DKA
- Been unwell

58
Q

If having hypo

A

Reduce insulin dose by 20%

Give long acting CHO

59
Q

What do you never do

A

Stop insulin as can lead to DKA

Endocrine (17 decks)

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