DM and Related Emergencies

Question 1

Definition of Diabetic Ketoacidosis/ Pathogenesis

Answer 1

It is a condition in which there is severe deficiency of insulin resulting in very high blood glucose level but unavailable to the tissues as a source of energy. Fat is therefore broken down as the alternative source of energy producing a byproduct- ketones. There is severe dehydration and electrolyte imbalance. It mostly occurs in type 1 DM but may occur in type 2 DM.

Question 2

Aetiology/ causes

Answer 2

This arises when you
—interrupt treatment or
—when there is stress or
— an inter-current illness-infections,
—MI,
— stroke,
—surgery
—Certain medicines, such as some diuretics (water pills) and corticosteroids (used to treat inflammation in the body).

Question 3

Signs and symptoms

Answer 3

Symptoms& Signs
•Excessive urination, thirst, drinking of water.
•Vomiting, abdominal pain.
•Altered sensorium
•Dehydration
•Deep , fast breathing
•Fast , weak pulse; low BP
•Smell of acetone
•Confusion or coma

Question 4

Investigations

Answer 4

Investigations
•RBS- usually> 18mmol/l
•Urine ketones- usually>2+
•For inter-current infections- MPs, WBC, blood/urine culture, chest x-ray for chest infection
•Electrolytes- BUE

Question 5

Treatment

Answer 5

Treatment
•If blood glucose>18mmol/l or urine ketones>2+
Give N/S 1L (1st liter) first 30mins; 1L (2nd liter) the next 1hr; 1L (3rd liter) the next 4hrs; 1L (4th liter) next 4 hours and subsequently 1L every 6hrs as required.
Give soluble insulin IV/IM 10-20units stat and thereafter 5units/0.1unit/kg IM 1hrly until the blood glucose is <11mmol/l
If urine output>30ml/hr put10-20ml potassium chloride into 500ml N/S to run for 1hour
NB- monitor blood glucose hourly& ketones twice a day
•If blood glucose <13mmol/l
Give 5% dextrose 1L every 6hours to prevent subsequent hypoglycemia
Then give soluble/regular insulin sc by sliding scale
•If blood glucose between 6-11mmol/l continue as a stable DM treatment-lente insulin bd
•Give broad spectrum antibiotics for suspected infections
•Give antimalaria for confirmed malaria/suspect

Question 6

Summary

Answer 6

Summary of DKA Treatment
•Treat the dehydration with Normal Saline
-First 30 minutes – 1 liter
-Next 1 hour – 1 liter
-Next 4 hours – 1 liter
-Next 4 hours- 1 liter
-Then every 6 hours as required – 1 liter
•Treat the hyperglycemia with soluble insulin
-Stat dose IV/ IM- 10-20 units
-Then IM every 1 hour until glucose level <11mmol/L – 5 units/0.1unit/kg

•Prevent hypoglycemia if glucose level <13mmol/l
-Give D5% 1 litre every 6 hours
-Then give soluble insulin sc by sliding scale
-Continue treatment as stable DM if blood glucose 6- 11mmol/l
•Treat low potassium if urine output> 30ml/hour
-10-20mls potassium chloride in 500mls Normal Saline to run for 1 hour
•Give broad spectrum antibiotics for suspected infections. Treat malaria if confirmed

Question 7

Slides scale

Answer 7

Sliding Scale
<6mmol/l no insulin
6.1-9.0mmol/l 4units insulin
9.1-12.0mmol/l 6units insulin
12.1-15.0mmol/l 8units insulin
15.1-18.0mmol/l 10unmits insulin
NB. When using sliding scale if the FBS> 16.0 reverse to the treatment of DKA

Question 8

Differentials for DKA

Answer 8

Differentials of DKA
•Hyperosmolar hyperglycemic state
•Gastroenteritis
•Pancreatitis
•Starvation ketosis

Question 9

Full meaning of DKA

Answer 9

Diabetic ketoacidosis