Diabetic Emergencies

Question 1

Pathogenesis of DKA

Answer 1

Glucose unable to enter cell, energy has to be obtained other ways, lipolysis increases producing free fatty acids which are converted via beta oxidation to acetyl- CoA which should be used in the TCA cycle but oxaloacetate is needed for gluconeogenesis so acetyl-CoA is converted to ketones causing acidosis, increased blood glucose exceeds kidney reabsorption capacity leading to glycosuria then via osmotic diuresis results in dehydration

Question 2

Causes of DKA

Answer 2

Non-adherence to insulin + diabetic management, newly diagnoses, infection, illicit drug + alcohol use

Question 3

Symptoms of DKA

Answer 3

Thirst, polyuria, dehydration, flushing, vomiting, abdo pain + tenderness, Kussmaul’s breathing acetone smell on breath

Question 4

Complications of DKA

Answer 4

Cardiac arrest due to hypokalaemia, ARDS, cereal oedema, gastric dilatation

Question 5

Diagnosis of DKA

Answer 5

Ketonaemia >3mmol/l, blood glucose > 11mmol/l, potassium > 5.5 mol/L, raised creatinine, lactate, amylase, low sodium, white cell count 25, bicarbonate <15mmol/l or venous pH < 7.3

Question 6

Treatment of DKA

Answer 6

Fluid resuscitation: 0.9% Sodium chloride, dextrose (when glucose falls to 15)
Insulin (0.1units/kg/hour), NG tube if GCS <12, prophylactic LMWH

Question 7

Risk factors of HHS

Answer 7

More common in T2DM, older patients, young afro-Caribbean, diabetes often not known at presentation, CV disease, sepsis, steroids, thiazide diuretics

Question 8

Symptoms of HHS

Answer 8

Can present over days, polyuria, polydipsia, nausea, dry skin, disorientation

Question 9

Diagnosis of HHS

Answer 9

Hyperglycaemia > 30mmol/l, no ketonaemia < 3mmol/l, osmolality > 320mosmol/kg, bicarbonate > 15mmol/l or venous pH > 7.3, high or normal sodium

Question 10

Treatment of HHS

Answer 10

Normalise osmolality (replace fluid + electrolyte losses but don’t fluid overload), normalise blood glucose

Question 11

Pathogenesis of alcohol/starvation ketoacidosis

Answer 11

Alcohol inhibits hepatic gluconeogenesis decreasing insulin secretion + ethanol is metabolised to acetone which is a ketone

Question 12

Symptoms of alcohol/starvation ketoacidosis

Answer 12

Dry and difficult to rouse, hypotensive, tachypnoea, abdo pain, vomiting

Question 13

Diagnosis of alcohol/starvation ketoacidosis

Answer 13

Ketonaemia > 3mmol/l, glucose low or normal, elevated anion gap metabolic acidosis, bicarbonate < 15mmol/l or venous pH <7.3, raised creatinine, high lactate or high white cell count

Question 14

Treatment ofalcohol/starvation ketoacidosis

Answer 14

IV parbinex, IV fluids (dextrose), IV anti-emetics, insulin may be required, address alcohol dependency

Question 15

Where is lactate found

Answer 15

RBCs, skeletal muscle, brain and renal medulla

Question 16

What is normal lactate levels

Answer 16

0.6-1.2mmol/l

Question 17

What causes type A lactic acidosis

Answer 17

Tissue hypoxaemia e.g. ischaemic bowel, cariogenic shock, hypovolaemic shock, sepsis + haemorrhage

Question 18

What causes type B lactic acidosis

Answer 18

Liver disease, leukaemia states, diabetes

Question 19

Symptoms of type B lactic acidosis

Answer 19

Hyperventilation + mental confusion

Question 20

Diagnosis of type B lactic acidosis

Answer 20

Reduced bicarbonate, raised anion gap, raised phosphate, no ketonaemia, variable glucose

Question 21

Treatment of type B lactic acidosis

Answer 21

Fluids, antibiotics