EcG Nd Diabetics Flashcards

Question

Where are the leads placed on the body 10 electrodes required to produce 12-lead ECG What does aVL,aVF and aVR mean

Answer 1

V1 Fourth intercostal space to the right of the sternum. V2 Fourth intercostal space to the left of the sternum. V3 Directly between leads V2 and V4. V4 Fifth intercostal space at midclavicular line. V5 Level with V4 at left anterior axillary line. V6 Level with V5 at the midaxillary line. (Directly under the midpoint of the armpit) R - Right arm(RA) L - Left arm F - Left leg(LL) N - Right leg aVR means augmented Vector Right; the positive electrode is on the right shoulder. aVL means augmented Vector Left; the positive electrode is on the left shoulder. aVF means augmented Vector Foot; the positive electrode is on the foot.

Answer 2

``` Regularity Rate QRS PR interval P waves ``` 5 large boxes is 1 second 300 large boxes is 60 seconds Rate is 300/number of large boxes

Answer 3

``` Sinus tachycardia •Look for the cause: •Infection •Autoimmune conditions •Drugs •Anxiety •Don’t forget pulmonary embolism in at-risk patients ``` Treat the cause •Usually that brings it down •Slow it down •Beta blockers •Monitor

Answer 4

Diabetic Ketoacidosis (DKA) is an acute metabolic complication of Diabetes caused by absolute or relative insulin deficiency. • Commonly occurs in patients in type 1 diabetes but also occurs is some patients with type 2 diabetes, often of Afro-Caribbean or Hispanic organ. (Ketosis prone type 2 diabetes)

Answer 5

PATHOPHYSIOLOGY • DKA is a complex disorder. Metabolic state is characterized by; 1. Known DM or Hyperglycaemia (RBS >11.1mmol/L) 2. Ketonaemia (>3mmol (< Ketonuria(>2+ on urine dipstick 3.Acidosis (pH <7.2 or 7.3and/ or Bicarbonate < 15mmol/L

Answer 6

Lack of insulin is accompanied by an increase in counter-regulatory hormones.(glucagon, cortisol, growth hormone and adrenaline) • Increase in counter-regulatory hormones results in enhanced hepatic gluconeogenesis and glycogenolysis leading to hyperglycaemia • Enhanced lipolysis increases free fatty acids which are metabolized to ketones (acetone, acetoacetate and 3- B hydroxy butyrate) and causes a metabolic acidosis Hyperglycemia leads to Glycosuria which leads to Osmotic diuresis (leads to loss of Loss of Na, Cl, Partial pressure of Oxygen, K Ca, Mg, and N ) leading to Decreased GFR leading to Severe hyperglycemia leading to Intracellular dehydration causing impaired consciousness or leading to Dehydration and Hemoconcentration causing Shock Ketoacidosis leads to vomiting ,metabolic acidosis,compensatory tachypnea leading to dehydration and hemoconcentration then shock Precipitants: Infarction Infection Not taking meds properly

Answer 7

IMPORTANT CAUSES OF DIABETIC KETOACIDOSIS ❖Omission or reduce daily insulin injection ❖Infection ❖Pregnancy ❖Hyperthyroidism ❖Substance abuse (cocaine) ❖Medication; steroids, thiazides, antipsychotics ❖Heat related illness ❖CVA ❖GI hemorrhage ❖Myocardial infection ❖Pulm0nary embolism ❖Pancreatitis ❖Major trauma ❖Surgery Differential Diagnosis For Diabetic Ketoacidosis • Alcoholic Ketoacidosis • Starvation Ketoacidosis • Renal Failure • Lactic acidosis • Salicylates • Ethylene • Methanol

Answer 8

SIGNS AND SYMPTOMS(Clinical Features) ➢Hyperglycemia typically results in polyphagia,polyuria and polydipsia ➢Cardiovascular – hypotension and tachycardia due to dehydration ➢Gastrointestinal – abdominal pain, nausea and vomiting ➢Respiratory – kussmaul`s breathing (respiratory compensation for metabolic acidosis) and the smell of acetone on the breath ➢Neurological – AMS, confusion, coma

Answer 9

INVESTIGATION (DKA) 1. Blood Ketone Level 2. Glucose (bedside meter and confirmed with a laboratory venous plasma sample. 3. Venous blood gas – assess acid-base status 4. Blood tests – urea, electrolytes, FBC, Cl and bi carbonate. 5. Infective screen – blood culture, urinalysis and culture, Ch𝑒𝑠𝑡 𝑋𝑟𝑎𝑦. 6. ECG and Cardiac monitoring 7. Urinalysis 8. Serum osmolality (2*(Na + K) + urea + glucose

Answer 10

SIGNS OF SEVERITY AND MARKERS OF POORER OUTCOME Need for HDU\ICU level care Biochemical Markers ✓Venous pH < 7.1 ✓HC𝑂 < 5mmol\L ✓Blood ketones > 6mmol/L ✓Serum osmolality > 320mmol\L ✓Hypokalemia on admission (k<3.5) SIGNS OF SEVERITY AND MARKERS OF POORER OUTCOME CONT. Patient Factors • Reduced level of consciousness • Hypotension • Hypoxia • Age > 65 years • Significant cardiac or Renal co—morbidity • Newly diagnosed diabetes • Oliguria

Answer 11

Goal of treatment ▪Correct volume deficit ▪Correct acid-base imbalance ▪Correct electrolyte abnormalities ▪Administer insulin ▪Treat the underlying causes

Answer 12

General Measures • Ensure patency and maintenance of airway • High flow oxygen should be given • If he patient is unconscious advanced airway management and intubation will be required • NG tube will be required if patient in vomiting or unconscious to prevent aspiration • Two (2) IV cannulae MANAGEMENT CONT. • Nil per mouth for at least 6hours (gastroparesis is common) • Urinary catheter • Broad-spectrum antibiotics if infection is suspected. • Consider LMWH eg, enoxaparin as prophylaxis against DVTs \PE Fluid Replacement: ➢Use normal (0.9%) saline to replace the fluid deficit ➢Average fluids loss in DKA is 100ml\kg ➢If the glucose ≤ 14mmol/L, than 10% Dextrose should be given at rate of 125ml\hr alongside the 0.9% sodium chloride ➢The insulin must not be stopped because it is required to switch of ketone production. Replace fluid if systolic bp is less than 90mmhg. 500ml 0.9% sodium (if sys BP <90mmhg) chloride over 10-15mins -Repeat if necessary • 0.9%sodiumchloride1Lover 1hr • 0.9%sodiumchloride1Lwith KCl over 2hrs • 0.9%sodiumchloride1Lwith KCl over 2hrs sodiumchloride1Lwith KCl over 4hrs • 0.9%sodiumchloride1Lwith KCl over 4hrs • 0.9%sodium chloride1L with KCl over 6hrs Insulin: 0.1iu/kg/hr KCL infusion: Deficit plus maintenance to correct Hypokalemia Treat the precipitant of the DKA and infection if present

Answer 13

0.1iu/kg/hr (70iu in 50 mls RL or NS over 10 hours so 7iu every one hour) insulin and keep checking ketones till they clear and check sugars every hour and when it goes down to 13mmol/L then set up DNS. Or when it goes down to 13mmol/L it is likely ketones have cleared so you put patient on sliding scale Insulin replacement ▪The only indication for delaying insulin is a serum K < 3.3mmo\L ▪Patients with initial serum K < 3.3mmo\L should receive fluid and K replacement prior to insulin ▪Fixed rate intravenous insulin infusion is now recommended rather than a sliding scale The rate of insulin infusion is 0.1 unit\Kg\ hour (ie 7 units\hour if the patient weighs 70Kg). For HHS, the rate of insulin infusion is 0.05iu/kg/hr ▪An initial bolus dose of insulin is no longer recommended. ▪The response to insulin infusion pump is reviewed after 1 hour. ▪If blood glucose is not dropping by 3-5mmol\hr and capillary ketone by 0.5mmol\hr, the rate of infusion is increased by 1U\hr. MANAGEMENT CONT. • Monitor blood glucose, capillary ketones and urine output hourly • Urea and Electrolytes 4-hourly, Venous blood gas 0,2,4,8,12 • Monitor urinary ketones • The fixed rate insulin is continued until ; 1. Capillary ketones is < 0.3 MANAGEMENT CONT. 2. Venous pH > 7.3 3. Venous bicarbonate > 18 4. No urinary ketones (may take longer to clear) • At this point If patient is eating and drinking regularly, change to SC insulin regimen and stop IV insulin pump 1-2 ours afterwards If patient is not eating and drinking, change to IV sliding scale.

Answer 14

So if patient comes with Hypokalemia, correct K deficit and give maintenance potassium Normokalemia- give maintenance KCl fluid Hyperkalemia: don’t give potassium but use the BIG KDrop for management of hyperkalemia Potassium replacement (KCL) ✓Potassium levels are often high on admission ✓Potassium levels however falls rapidly under the action of insulin ✓Regular potassium monitoring is mandatory Suggested regimen for potassium. supplementation; Plasma potassium (mmol\L): a.If > 5.50mmol\L b.If. 3.5-5.5mmol\L c.If < 3.5 Amount of K(mmol) to add to each litre of fluid a.Nil b.Do 40mmol\L c.Do 60-80mmol\L (HDU support required, seek specialist advise. NB: Monitor urine output to ensure > 30ml\hr

Answer 15

Patients with DKA can be converted to an appropriate SC insulin regime when biochemically stable (blood ketone < 0.3 and pH> 7.3) and the patient is ready and able to eat.

Answer 16

DIFFERENCE IN MANAGEMENT BETWEEN ADULT AND PEDIATRIC DKA Fluid management in children with DKA • Resuscitation fluids – if child is shocked (weak peripheral pulse, prolonged capillary refill, with tachycardia, and\or hypertension) they should receive bolus of 10ml\kg 0.9% sodium chloride. This can be repeated up to 3 times (30ml\kg) • Rehydration fluid – is calculated based on the percentage dehydration multiplied by the body weight (kg) e.g, Deficit=%Dehydration×𝐵𝑜𝑑𝑦𝑤𝑒𝑖𝑔h𝑡 𝑘𝑔 The degree of dehydration can be estimated from the child`s clinical features. • Maintenance fluids – The APLS formula. The APLS maintenance fluid requirement ; Weight (kg) - ml\kg\24h First 10 kg - 100ml Second 10 kg – 50ml Subsequent kg – 20ml Once shock has been treated fluids are calculated over a 48hr period using the following formula; 48 fluid requirement= Maintenance+ Rehydration- Resuscitation already given Estimating the degree of dehydration: Percentage dehydration a.Mild, 3% b.Moderate, 5% c.Severe, 8% d.Shocked Clinical features a.Only just clinically detectable b.Dry mucous membranes, reduced skin turgor c.As for moderate plus sunken eyes, poor capillary refill. d.Severely ill with poor perfusion, thready rapid pulse

Answer 17

COMPLICATIONS OF DKA • Hypokalaemia and hyperkalaemia • Hypoglycaemia • Cerebral oedema • Pulmonary oedema • Aspiration pneumonia • CVA • MI •Seizures due to acidosis leading to cerebral edema Most DKA patients are dehydrated