Diabetic emergencies

Question 1

DKA criteria

Answer 1

Ketones >3
Bicarbonate <15
pH <7.3
Glucose >11.1

Question 2

Fluid management in DKA

Answer 2

If SBP <90 - 500ml 0.9% NaCl stat
When SBP >90 - 1000ml 0.9% NaCl over 60m with K added

If SBP >90 on admission - 1000ml 0.9% NaCl 1hr

THEN (all with K) - 1l 2hrs X2, 1l 4hrs X2, 1l 6hrs

Question 3

Insulin infusion in DKA

Answer 3

Carry on patient’s own long acting
50 units of Act Rapid in 49.5ml 0.9% NaCl (50ml) at concentration of 1unit/ml.

Rate = 0.1 unit/kg/hr

Question 4

Glucose replacement in DKA

Answer 4

Add 10% glucose 125ml/hr to bag when BM <14

Question 5

Monitoring in DKA

Answer 5

Hourly BM, hourly ketone
Venous bicarbonate, K at 60m 2hrs + then 2 hourly
4hr plasma electrolytes

At 12h - check venous pH, bicarbonate, K, capillary ketones + glucose

Ongoing euro obs

Question 6

Aim of DKA tx

Answer 6

Fall of ketones by 0.5mmol/l/hr
BM fall 3mmol/l/hr
By 24hr - ketonaemia + acidosis should be resolved

Question 7

DKA resolution

Answer 7

Ketones <0.3, venous pH > 7.3

Question 8

When to stop insulin infusion in DKA?

Answer 8

When resolved - transfer to S/C when pt is eating/drinking - discontinue IVII 30m after S/C short acting given

Question 9

Hyperglycaemia hyperosmolar state criteria

Answer 9

Severe hyperglycaemia with serum hyperosmolarity without significant ketosis

• Longer history
• Marked dehydration
• BM >30
• Ketones <3
• Normal pH
• Plasma osmolality >320
• Bicarbonate >15

Question 10

Normal plasma osmolarity

Answer 10

290 +/-5

Question 11

How to calculate plasma osmolality

Answer 11

2 (Na + K) + urea + glucose

Question 12

Management of HHS

Answer 12

Fluid replacement over 48h - may need 9-10l. 1000ml NaCl over 1st hour

Low dose fixed rate IVII 0.05 units/kg/hr only if blood glucose no longer falling with IV fluids alone (or immediately if ketones >1)

K replacement, glucose when BM <14, LMWH, foot protection

TREAT CAUSE

Question 13

How quickly should things reduce in HHS?

Answer 13

Na should fall by no more than 10mmol/l in 24h

Fall in BM no more than 5mmol/h

Fluid balance should be 3-6 litres +ve by 12hrs

Question 14

Monitoring in HHS?

Answer 14

Hourly BM, Na, K, urea + calculated osmalility for 1st 6hrs then 2 hourly is satisfactory response

Question 15

How to calculate anion gap

Answer 15

Cations (Na + K) - anions (Cl + HCO3)

Question 16

Normal anion gap metabolic acidosis (also known as hyperchloremic acidosis)

Answer 16

Primary loss of HCO3 compensated with increased Cl

Question 17

Causes of normal anion gap metabolic acidosis

Answer 17

Endogenous causes = diarrhoea, biliary/pancreatic fistula, renal tubular acidosis, addison disease

Exogenous causes = drugs (carbonic anhydrase inhibitors), uptake of acids containing Hcl

Question 18

High anion gap metabolic acidosis

Answer 18

Increased concentration of organic acids e.g. lactate, ketoacids, glycolic acids. No compensatory increase of Cl so high anion gap

Question 19

Causes of high anion gap metabolic acidosis

Answer 19

PLUK
Poisons - methanol, ethanol, iron, ethylene glycol, salicylates 
Lactate
Urea 
Ketones

Question 20

Lactic acidosis

Answer 20

Inadequate clearance of lactic acid from blood - usually caused by tissue hypoperfusion +/- hypoxia

Question 21

Normal anion gap range

Answer 21

Approx 8-16 (not including K), 10-20 (including K)

Question 22

Causes of hypoglycaemia in non diabetics patients

Answer 22

ExPLAIN
Exogenous insulin 
Pituitary insufficiency 
Liver failure 
Adrenal insufficiency 
Insulinoma 
Nutritional deficiency

Question 23

How to treat hypoglycaemia

Answer 23

Patient conscious = 7x glucotabs, glucojuice, jelly babies, glucoses

Pt not awake

• IV access = 100ml 20% glucose
• No access = IM glucagon

Then give patient carbohydrates