Diabetic Emergencies Flashcards

Question

What should you do if you have nocturnal hypoglycaemia

Answer 1

Confirm by advising testing blood glucose levels during the night (3.00am), or using continuous glucose monitoring sensor (CGMS), which monitors glucose over 5 days subcutaneously

Answer 2

 Analogueinsulins  Pre bed snack  Change timing of insulin  Insulin pump therapy

Answer 3

A state of absolute or relative insulin deficiency resulting in hyperglycemia and an accumulation of ketoacids in the blood with subsequent metabolic acidosis

Answer 4

Hyperglycemia  Blood glucose >14 mmol/L Acidosis  pH < 7.30  Bicarb < 15 mmol/L Ketosis  Elevated serum or urine ketones - 2 or 3 + ketones in the urine

Answer 5

- Catecholamines excess (unopposed) | - Insulin deficiency

Answer 6

Catecholamines excess (unopposed) - promote triglyceride breakdown to free fatty acids and glycerol - stimulates gluconeogensis Insulin deficiency - inhibits gluconeogensis

Answer 7

Ketosis due to FFA metabolism due to absolute or relative deficiency of insulin

Answer 8

Acidosis is caused by ketone body accumulation: |  3-OH-butyric acid and acetoacetic acid

Answer 9

- terminated instantaneously by insulin

Answer 10

 Often a short history  Abdominal pain and vomiting is common – can present as an acute abdomen - can be very severe  Kussmaul’s respiration – deep sighing respirations due to acidosis  Ketones on breath (remember ~40% people cannot smell these)  Drowsiness, confusion  Dehydration and Tachycardia - polyuria and polydipsia - vomiting

Answer 11

- Water = 6.8 L - Sodium = 500-1000mmol - Chloride = 350mmol - Potassium - 500-1000mmol - Calcium - 50-100mmol - Phosphate - 50-100mmol Magenisum - 25-50mmol

Answer 12

```  Insulin omission (see notes later on “sick day rules”)  Infection  Pregnancy  Myocardial Infarction  Intoxication / drugs  Unknown in ~40% ```

Answer 13

 Venous blood gases show acidosis (pH <7.35, bicarb <15)  Capillary Blood Glucose (CBG) - usually over 14 mmol/L, but can be lower (euglycaemic ketosis or alcoholic ketosis)  Frequently raised Urea and Creatinine  Urine or plasma ketones - elevated

Answer 14

```  Pregnancy test  ECG / CXR  MSU / Blood Cultures  Biochemical Profile / lab glucose  FBC  HbA1c ```

Answer 15

```  Blood ketones > 6 mmol/L  Bicarbonate < 5 mmol/L  pH<7.1  Potassium < 3.5 mmol/L  GCS <12  O2 sats < 92%  Systolic BP < 90 mmHg  Pulse >100 or < 60 bpm ```

Answer 16

 Level 2 bed (High Dependency Unit)  Cardiac monitor = loss of potassium  Nasogastric tube if impaired conscious level - prevent aspiration  Consider Central Venous Pressure line – especially in elderly if concern with cardiac problems  Oxygen if PaO2 < 10.5 kPa on air  Urinary catheter  Prophylactic LMW heparin  iv antibiotics as appropriate if suspected infection  Frequent monitoring of conscious level, BP, Pulse, Temp, Glucose, Urine output, Potassium, Acidosis

Answer 17

Sodium chloride 0.9% - 1 Litre stat - 1 Litre in 1 hour - 1 Litre over 2 hours (+20 mmol potassium chloride) - 1 Litre over 4 hours (+potassium chloride) - 1 Litre over 4 hours (+potassium chloride) 5% or 10% Glucose - Start when the CBG is <12 mmol/L and continue at 125ml/hr - 10 % glucose may be necessary to increase insulin infusion - Increase infusion rate if glucose falls below 6.0 mmol/L - given glucose so you can given insulin - insulin has a short half life so when it switches of you can become ketoacidotic again

Answer 18

- For the first 1-2 bags fluid, give no potassium as fluid is given too rapidly - For every subsequent bag of NaCl 0.9% or glucose 5% use a bag of fluid containing KCl as follows according to serum K+: - less than 3.5 - may need additional potassium and delay insulin - cause potassium to plummet further and can cause arrthymia - 3.5-5.5 - 20-40mmol/L - greater than 5.5 - none

Answer 19

- If the patient is known to be diabetic continue their normal long acting insulin on admission - commence insulin infusion by intravenous syringe pump - contains 50 units of actrapid made up to 50mlin sodium chloride 0.9% fixed rate IV insulin infusion - 0.1u/kg - around 6-8 u/hour for most patients - aiming for bicarbonate rise of 3mmol/hour and glucose fall by 3 mol/hour - if not achieved increase the rate by 1u/hour

Answer 20

Cerebral oedema - indicated by sudden CNS decline - treatment - dexamethasone or mannitol

Answer 21

- dexamethasone | - mannitol

Answer 22

 Return to usual subcutaneous insulin once eating and drinking reliably  Until ketones clear, patient is likely to be nauseated and not able to eat normally  Persisting ketonuria usually reflects lack of adequate glucose and insulin administration  Education in self-care and sick-day rules (see later) to help prevent future DKA – usually done by Diabetes Nurse Specialist

Answer 23

type 2 diabetes | - longer subacute history

Answer 24

Hyperglycaemia often >40 mmol/L

Answer 25

 Hyperglycaemia often >40 mmol/L Osmolality >340 (275-295)  Can be estimated by the formula 2x[Na+K]+Ur+Glu  Patient is often hypernatraemic  They may or may not have ketonuria – frequently “+” if not eating  No (keto) acidosis, but may have lactic acidosis  Severe dehydration  66% previously undiagnosed DM

Answer 26

Osmolality >340 (275-295)  Can be estimated by the formula 2x[Na+K]+Ur+Glu  Patient is often hypernatraemic

Answer 27

 IVI as for DKA – but consider slower fluids if elderly / heart failure  NO INSULIN BOLUS - for first 12 hours  Much lower dose insulin – maybe no insulin for 1st 12 hours, then very low doses – perhaps 1 u/hr  Rapid shifts in glucose should be avoided due to risk of rapid fluid / sodium shifts, and risk of central pontine myelinolysis (CPM)  Correct BG at maximum 2 mmol/L/hr  Central venous pressure monitoring may be required  s/c Low Molecular Weight heparin may help reduce thrombosis  K+ tends to decline rapidly  Avoid 0.45% N Saline  Accept that biochemistry will be abnormal for days or risk hypernatraemia, CPM, cerebral oedema

Answer 28

 Try to drink fluids ++  If you are unable to eat, drink sugary fluids, e.g. fruit juice  Monitor glucose levels more regularly  Never stop your tablets or insulin – indeed insulin doses may need to be increased as you are “stressed”  People who normally take oral agents may need to be transferred on to insulin for the duration of illness  If you are unable to keep fluids down, come straight to hospital

Answer 29

- hyperglycaemia resulting in high osmolarity without significant ketoacidosis

Answer 30

- aspiration pneumonia - hypokalaemia, hypomagenseia, hypo phosphate - VTE - cerebral oedema

Answer 31

- consumption of glucose rich fluids - concurrent medication such as thiazide diuretics or steroids - intercurrent illness

Answer 32

- occlusive events: stroke , MI, DIC, leg ischaemic, DVT/PE, | - give LMWH as prophylaxis

Answer 33

Rehydrate slowly (consider age and CCF) over 48hrs with 0.9% NaCl (IVI) - Typical deficit = 110-220ml/kg (~8-15L) - Avoid 0.45% NaCl No insulin bolus – Only use insulin if blood glucose is not falling by 5mmol/L/hr with rehydration or ketonuria; Slow infusion of 0.05units/kg/hr (max 1unit/hr); Avoid in first 12hrs - Rapid shifts in glucose should be avoided due to risk of rapid fluid/Na+ shits and central pontine myelinosis (CPM) Replace K+ when urine starts to flow - May need CVP monitoring - K+ ↓ rapidly - Keep plasma glucose at 10-15mmol/L for first 24hrs to avoid cerebral oedema - Look for cause, eg bowel infarct, drugs, etc.

Answer 34

- Benefits - Risks - Adverse effects - Interactions - Necessary prophylaxis - Susceptible groups - Administering - Informing - Monitoring - Stopping