Diabetic emergencies

Question 1

What is DKA?

Answer 1

A serious, life-threatening complication of diabetes which occurs when the body begins to metabolise fat as an energy source due to lack of insulin.

Question 2

What are Sx of DKA?

Answer 2

Nausea and vomiting
Signs of dehydration
Abdominal pain
Confusion/drowsiness/reduced GCS
Acetone breath
Kussmaul breathing and hyperventilation 

Also Sx of diabetes: thirst, polyuria

Question 3

What are triggers for DKA?

Answer 3

Infection 
Alcohol
MI
New diagnosis of diabetes 
Missed insulin dose
Steroids

Question 4

What is pathogenesis of DKA?

Answer 4

Owing to lack of insulin, body metabolises energy stores for glucose e.g. fatty acids into ketones following lipolysis

Ketones cause acidosis

The body moves K into bloodstream to swap with increased H circulating.

NaK pump doesn’t work (it needs insulin) so excess K in blood

K is excreted by kidneys, but patients can look normo/hyperkalaemic despite being deplete

Question 5

How is DKA diagnosed?

Answer 5

• Glucose: >11 OR Known diabetes
  
  • Metabolic acidosis: pH <7.3 (H > 45) or Bicarb <18
  • Ketones: plasma >3 mmol/l or ++ on urine dip

Question 6

What are severe criteria for DKA?

Answer 6

Reduced GCS (<12)

Severe acidosis

Hypokalaemia (<3.5)

Ketones > 6

O2 sats < 92

Cerebral oedema

Consider HDU or ICU

Question 7

What are the 4 principles of DKA management?

Answer 7

1. Fluid replacement: IV crystalloid. 1L over first hour, then slowly to avoid cerebral oedema
2. IV Insulin: fixed rate IV 6 units/hour
3. IV Dextrose: to allow continued suppression of ketogenesis
4. Correction of hypokalaemia: add K to each 500ml bag of fluid.

Question 8

When should dextrose be started and insulin reduced?

Answer 8

When blood glucose <14

This allows ongoing suppression of ketogenesis.

Question 9

What other important Ix in DKA?

Answer 9

ECG: K
Catheter if oliguris
Blood cultures if pyrexial

DVT prophylaxis

Question 10

What needs to be done before patients are discharged?

Answer 10

• Resolution of acidosis pH >7.3 Bicarb >15 
	• Resolution of ketonaemia <0.6mmmol/L 
	• Eating and drinking 
	• Given long acting insulin 
Review by Diabetes team

Question 11

What are complications of DKA?

Answer 11

• Mortality 0.67%
  
  • VTE
  • Arrhythmias (due to K disorders)
  • Cerebral oedema
  • ARDS
  • AKI

Question 12

What are differentials for DKA?

Answer 12

HHS
Alcoholic ketoacidosis
Lactic acidosis

Question 13

What is HHS?

Answer 13

A complication of diabetes characterised by profound hyperglycaemia and osmotic diuresis

Question 14

What are Sx of HHS?

Answer 14

• Acute cognitive impairment
	• Hypovolaemia 
		○ Tachycardia, hypotension, dry mucus membranes 
	• Insidious history (>1 week)
		○ Polyuria, polydipsia, 
Usually older patients

Question 15

What are triggers for HHS?

Answer 15

• Infection (pneumonia and UTI common)
• Poor compliance with diabetes medications
• Other drugs e.g. steroids, antipsychotic
Acute illness e.g. MI, sepsis, stroke

Question 16

How is HHS diagnosed?

Answer 16

• Hyperglycaemia (>30)
	• Serum osmolality >320
	• H ions < 50
	• HCO3 > 15
Ketones <3 

Also U+Es, FBC, ECG, WCC and CRP if infection possible trigger

Question 17

What are DDx for HHS?

Answer 17

DKA
alcoholic ketoacidosis
lactic acidosis

Question 18

What is Rx of HHS?

Answer 18

• Treat the precipitant

• Fluids
	○ 0.9% saline over 48 hours, 1L over first hour 
	○ Aim for positive fluid balance of 3-6L by 12 hours 

• Insulin
	○  if glucose is not falling by 5mmol/L/hour with fluids 

• LMWH

Replace K when urine starts to flow

Monitor electrolytes

Refer to critical care

Question 19

What is hypoglycaemia?

Answer 19

Low blood glucose

Question 20

What is whipple’s traid for hypoglycaemia

Answer 20

• Symptom of low blood glucose: autonomic or neuroglycopaenic
  
  • Measured plasma glucose:
    ○ < 2.8mmol - normal
    ○ < 4.0mmol – insulin-treated DM
  • Better after glucose

Question 21

What are Sx of hypoglycaemia?

Answer 21

Autonomic Sx (due to release of glucagon and adrenalien): sweating, palpitations, shaking, nausea, anxiety

Neuroglycopaenic Sx: confusion, drowsiness, incoordinatoin, weakness, tired

Question 22

At what glucose levels do Sx of hypoglycaemia occur?

Answer 22

4: autonomic
2. 5-3: neuroglycopaenic

<2: EEG changes and seizures

<1.5: coma

Question 23

what are differentials for hypoglycaemia?

Answer 23

Diabetes
non-diabetes

Delirium

Postural hypotension (if fall)

Stroke

Question 24

What are risk factors for hypoglycaemia?

Answer 24

Diabetes

sulphonylurea use

too much insulin

not enough food

Question 25

What is Rx of mild hypoglycaemia?

Answer 25

Conscious and oriented, give • 15-20g quick acting carb e.g. 200ml orange juice or glucotabs
Recheck blood glucose in 10-15 minutes

Repeat up to 3x

Give 20g long-acting carb

Question 26

What is Rx of moderate hypoglycaemia?

Answer 26

Conscious and able to swallow, but uncooperative

Squirt glucose gel between gums. if ineffective, give glucagon 1mg IM

Give 20g long-acting carb

Question 27

What is Rx of severe hypoglycaemia?

Answer 27

Unconscious

IV glucose over 10 mins, or glucagon IM (not if malnourished)

Give 20g long-acting carb