Diabetic Emergencies Flashcards
When can you get DKA
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
What causes DKA and what is the triad
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
What are precipitating factors
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
What should you do if unwell or BG >14
Check ketones
If ketones <1.4 what do you do
Have sugar free fluid
Correct insulin
Recheck levels
What do you do if ketones <2.9
Contact DM tean
If ketones >3 what do you do
Urgent medical advice
What are features of DKA
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
How do you Dx DKA
Glucose >11
pH <7.3
Bicarb <15
Ketones >3 or +ve on dip
When do you involve consultant
Hypokalaemia - lost in diuresis as not taken into cells (insulin drives in)
Reduced consciousness
Cerebral oedema
Severe DKA
When is DKA severe and what should you do
pH <7.1
HCO3 <5
Involve ICU early if pH <7.1
Call up
Mild <7.3
Mod <7.2
What do you do initially
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
How do you Rx if shock and no shock
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
When do you start dextrose infusion
When BG falls to <15 to prevent hypoglycaemia
Runs alongside saline
10% glucose unit at 125ml / hour along with saline
How do you correct hypokalaemia
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
What else should you consider
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
What are risks of DKA
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
What are signs of cerebral oedema
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
How do you Dx and RX
Regular review - pads get GCS tested every 1 hour Head CT Senior review Slow fluids IV mannitol IV hypertonic saline
What should you do if unwell
Never stop insulin
BG monitoring + ketone testing
May need extra doses
Regular CHO even if BG high
What causes hypoglycaemia in diabetic
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
Who is at risk of hypoglycaemia
Tight control Impaired awareness Age extremes Abrupt steroid withdrawal / hypoadrenalism Malabsorption / coeliac Renal / hepatic impairment Pregnancy
What causes impaired awareness (no symptoms but still need treated if BG <4)
Neuropathy = most common Recurrent hypoglycaemia Long duration Overtight control Loss of sweating or tremor
What does hypoglycaemia cause
Autonomic Sx
Neuro Sx
General
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
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)
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
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
If ar risk of hypo what should you have
Hypobox Fruit juice Glucogel 50% dextrose Hypo management protocol
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
How do you avoid hypo
Regular monitoring
Rotate injection
Regular carb counting
If driving
Check BG before and every 2 hours
Carry CHO
No more than 1+ hypo in a year
What is body’s response to hypo
Decreased insulin
Increased glucagon
GH + cortisol release
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
Why may not appear dehydrated
Hypertonicity preserves intravascular volume
Who typically presents
Elderly
Type II UnDx
What are features
Fatigue Lethargy N+V Altered consciousness Papilloedema Weakness Hyperviscosity Dehydration Hypotension Tachycardia
What is important to do
Differentiate from DKA
What are complications
Pressure ulcer VTE - Big risk due to thick sugary syrup MI Stroke PAD Seziure Cerebral oedema Central pontine myelinolysis
How do you Dx
Hypovolaemia
Marked hyperglycaemia + no ketones
Raised serum osmolarity >320
If not dehydrated + Na / urea normal then unlikely
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
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
Caution
Elderly
HF
CKD
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
What kills in DKA
Acidosis from ketones or renal failure
Severe dehydration or electrolyte disturbance - K
Impaired consciousness due to raised osmolality or ketones
What does kidney do try and correct DKA
Produce bicarb but eventually store runs out and become acidotic
If bicarb low = life threatening
What causes signs of DKA
Hyperglycaemia filtered into urine Draws out water = osmotic diuresis Produce polyuria Severe dehydration Stimulates thirst = polydipsia
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
How fast should K be corrected
No more than 10mmol / hour
If hyperglycaemia but no ketones
May need extra insulin
1 unit RA reduce insulin by 4mmol
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
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
What else should you do in DKA
Check VBG regular
Check potassium
When do you stop fixed rate insulin
Ketones <0.3
pH >7.3
Patient can eat and drink
DDK of hypo / what can mimc
DKA Substance withdrawal / alcohol Stroke - Slurred speech etc so always check Seizures Reduced GCS
What should anyone with reduced GCS get
Blood glucose
What is euglycaemic DKA
If on SGLT-2 inhibitor Due to glucose diuresis caused by drugs High ketones Acidosis Normal glucose
Diff hypo and hyper
Hypo
- More acute
- Too much insulin / not enough food
DKA
- Been unwell
If having hypo
Reduce insulin dose by 20%
Give long acting CHO
What do you never do
Stop insulin as can lead to DKA
