Diabetic med emergencies

Question 1

contributing factors to hypoglycaemic episode? (case study)

Answer 1

diet change in hospital- not matched my med adjustment
increased activity form physio-not matched by increased cards/ med adjustment
low HbA1c
sulfonylurea: gliclazide -> hypoglycaemia
renal impairment

Question 2

how would you improve px blood glucose conc?

Answer 2

stop/ reduce evenign dose of gliclazide… not metformin- doesnt cause hypo but closely monitor in renal imp and avoid in eGFR< 30

Question 3

hypoglycaemia ,most common AE of what?

Answer 3

diabetes treatment, result form imbalance between glucose supply and insulin conc

Question 4

hypoglycaemia defines as what conc for hospital px?

Answer 4

BG less than 4mmol/L

Question 5

2 types of symptoms of hypoglycaemia?

Answer 5

autonomic
neuroglycopenic

Question 6

autonomic (early) symptoms of hypoglyc

Answer 6

hunger
pallor
palps
restless
sweat
tachycardia

Question 7

neuroglycopenic (late) symptoms of hypoglyc

Answer 7

anxiety
blurred vision
confusion
drowsy
nose lips fingers numb
slurred speech

Question 8

lifestyle risk factors for hypoglycaem

Answer 8

diet
age
unawareness
fatsing ramadan
early preg and breastfeed
history of severe hypog
exercise/ physio

Question 9

med Hx risk factors for hypoglycaem

Answer 9

insulin/ antidiabetic meds
BG monitoring problems
comorbidity
Hx of severe hypoglyc
concomitant med
renal dysfunc- dialysis/ AKI
learning difficiulties

Question 10

mild hypoglycaemia can usually be reversed in approx 10 mins by the prompt admin of 15-20g of?

Answer 10

quick acting carbohydrate in conscious person

Question 11

what does severe hypoglycaemia require parenteral treatment with?

Answer 11

IM glucagon or IV glucose

Question 12

conscious confused px with diabetes, how to treat?

Answer 12

check ABCDE…. if not capable (conscious):

2 tubes 40% glucose gel
squeeze into mouth between teeth and gums

Question 18

how might age be a risk factor for hypoglycaemia

Answer 18

episodes more likely in older people

Question 19

how might excercise be a risk factor for hypoglycaemia?

Answer 19

increased levels of excercise not matched with antidiabetic treatment and mobilisation after illness

Question 20

true or false: medcation should not be stopped or withheld before discussing with the diabetes team?

Answer 20

true

Question 21

concious confused patients can either be given 1.5-2 tubes of glucogel or dextrogel or im glucagon at what strength?

Answer 21

1mg

Question 22

how many cycles can glucogel be repeated up to if blood glucose remains above 4 mmol/L?

Answer 22

3

Question 23

for concious confused patients what IV infusion can be considered if blood glucose remains above 4 mmol/L?

Answer 23

10% glucose 150-200ml over 15 mins

Question 24

for semi or unconcious pateint with IV access what should be given?

Answer 24

75-100 ml glucose 20% over 15 mins or 150-200ml glucose 10% over 15 mins

Question 25

for semi or unconcious patients that have no intravenous access what should be given once only?

Answer 25

im glucagon 1mg

Question 26

patients administered glucagon should be given a larger carbohydrate snack 40g or meal, why is this the case?

Answer 26

enable glycogen stores to be replenished

Question 27

what 2 things should be done if you dont find a convincing explanation for unexplained severe sponataneous hypoglycaemia (blood glucose conc below 2.2 mmol/l)?

Answer 27

1. take blood samples for lab glucose measurement to and serum measure insulin c peptide and insulin growth factor
2. give enough glucose orally or iv 20% solution to restore blood glucose to normal

Question 28

true or false, patients have a legal responsibility to inform DVLA if they have diabetes and are treated with certain drugs?

Answer 28

true

Question 29

DKA is a complex disordered metabolic state with what 3 characteristic features?

Answer 29

hyperglycaemia, metabolic acidosis and ketonaemia

Question 30

DKA often seen in T1DM but may also occur in…

Answer 30

px on SGLT2 inhibitors
with ketosis prone T2DM

Question 31

D in DKA refers to blood glucose> Xmmol/l

Answer 31

11 (diabetes mellitus)

Question 32

for dka ketoanemia means that blood ketones are equal to or above x mol/L?

Answer 32

3

Question 33

what are principles of treating dka?

Answer 33

replace fluids
correct electrolyte abnormalities
replace insulin
gradually reduce serum glucose conc
gradually correct ketosis
identify treatment of co morbid precipitants

Question 34

why is the most appropriate first intervention for dka fluid replacement?

Answer 34

restore circulatory volume, aid clearance of ketones and correction of electrolyte imbalances

Question 35

the second step of dka treatment is commencing insulin therapy as a fixed rate iv infusion, how is this calculated?

Answer 35

0.1 units/kg/hr

Question 36

what if there is a delay in setting up or prescribing the insulin infusion for step 2 of the dka management pathway?

Answer 36

single bolus dose of im insulin 0.1 units/ kg

Question 37

for dka ketones should be measured every hour and should fall by X mmol/l/hr. If not the patient may require an adjusted rate of insulin infusion?

Answer 37

0.5

Question 38

for dka capillary glucose should be measured every hr and the concentration should fall by X mmol/l/hr?

Answer 38

3

Question 39

for dka potassium must also be measured, it is usually high on admission but falls with insulin admin. do not give additional potassium if serum conc is above x mmol/l?

Answer 39

5

Question 40

dka is most often seen in patients with T1DM but can occur severely in patients with T2DM if they are taking what drug?

Answer 40

sglt2 inhibitors

Question 41

true or false, dkas that have occured due to sglt2 inhibitor use must be reported via the yellow card scheme?

Answer 41

true

Question 42

all patients on a sglt2 inhibitor must be conselled to recognise the signs and symptoms of dka, list some of these?

Answer 42

weight loss, nausea, vomiting, fast breathing, stomach pain, sweet smelling breath

Question 43

true or false, patients presenting with HHS will often not have a previous diagnosis of diabetes and this could be the initial presentation?

Answer 43

true

Question 44

what is hhs?

Answer 44

hyperosmolar hyperglycaemic state

Question 45

give 3 characteristic features of HHS?

Answer 45

hypovolemia, marked hypoglycaemia above 30mmol/l and raised osmolarity above 320 mosmol/kg

Question 46

what are the stepwise principles of treating HHS?

Answer 46

normalise osmolarity
replace fluids
monitor and replace electrolytes
normalise blood glucose
minimise risk

Question 47

what would be indicative of Hyperosmolar Hyperglycaemic State (HHS) over Diabetic Ketoacidosis (DKA)

Answer 47

Blood ketones <3 mmol/litre and bicarbonate >15 mmol/litre.

Ketones and metabolic acidosis are usually not present in HHS.
Marked hyperglycaemia >30 mmol/litre is a feature of HHS.
Other characteristics features include hypovolaemia and raised osmolarity (> 320 mosmol/kg).

Question 48

blood glucose should fall by no more than which ONE of the following when rehydrating in HHS?

Answer 48

5mmol/hour