EcG Nd Diabetics Flashcards
What is DIabetes what May it be due to
When will type 1 be detected
When will type 2 usually be seen
How do you diagnose gestational diabetes
It is a chronic metabolic disorder characterized by persistent hyperglycemia.
May be due to impaired insulin secretion, resistance to peripheral actions of insulin, or both.
Type 1 is usually detected incidentally and it’s detected early
Type 2 usually Comes Late and presents w complications
Diagnosed using OGTT cuz there’s impaired fasting blood glucose
It’s diagnosed from second trimester
What are the characteristics of the types of diabetes and the characteristics of gestational diabetes
Type 1:
Characterised by autoimmune destruction of insulin-producing beta cells of the pancreas
•Leads to absolute insulin deficiency
•Accounts for 5-10%
•Most commonly seen in children and adolescents (can be at any age)
Type 2:
Defined by insulin resistance.
•Progressive loss of β-cell insulin secretion
•Account for ~90% of all cases
•Most common >45 years (can occur at any age)
•Risks: Obesity, physical inactivity, energy-dense diets
Gestational:
- Hyperglycaemia first detected in pregnancy
- Usually occurs in 2nd and 3rd trimesters
- Complicates 7% of all pregnancies
State the risk factors for type 2 diabetes
Define two other types of diabetes and give two examples of each
Family history of Type 2 DM (parent or sibling with Type 2 DM)
•Obesity
•Sedentary lifestyle
•Race/ethnicity (African/Hispanic/Native/Asians)
•Previously identified IFG or IGT
•History of GDM or delivery of baby >4 kg
•Hypertension
•Dyslipidaemia
•Polycystic ovary syndrome or acanthosis nigricans
•History of vascular disease
Monogenic Diabetes
Caused by a single mutation in an autosomal dominant gene
LADA and MOD1
Secondary Diabetes
Due to complications of other diseases
Prednisolone causing diabetes
Endocrine diseases
Auto immune destruction of the pancreas
Name some causes of secondary diabetes
Diseases of Exocrine pancreas
•Cystic Fibrosis
•Pancreatitis
- Drugs or chemicals
- Glucocorticoid use
- after organ transplantation,
- drugs used in the treatment of HIV/AIDS,
- Thiazide diuretics
- Phenytoin
- Associated with genetic syndrome
- Down Syndrome
- Klinefelters Syndrome
- Excess endogenous production of hormonal antagonists to insulin:
- Growth hormone: acromegaly
- Glucocorticoid: Cushing’s syndrome
- Glucagon: Glucagonoma
- Catecholamines: Phaeochromocytoma
- Thyroid Hormones: Thyrotoxicosis
How is diabetes diagnosed using FBs,RBS,HbA1C,OGTT
FBS of more than 7mmol/L or 126 mg/dL ,checked twice four hours apart
If checked once the patient must have typical signs (weight loss(common in type 1), polyphagia,polydypsia,polyuria )
Or RBs of more than 11.1 mmol/L or 200mg/dL
And HbA1C of more than 6.5 or 48mmol/mol
OGTT:
When fasting your glucose is more than 7mmol/L . Less than 7 is normal
Two hours after taking the glucose your blood level of glucose is more than 11.1mmol/L . Less than 7.8 is normal
Results are from venous plasma cuz whole blood values are lower
Name some supportive investigations
Name four acute complications
Name ten chronic complications
People will present to the emergency with acute complications true or false
•Urine microscopy and dipstick: there’s a difference between microscopy and dipstick
Dipstick is a chemistry stick. 30s the lowest and the 120s the highest
Measures glucose,protein,bilirubin,urobilinogen,specific gravity,leukocytes,blood or Haemoglobin ,ketones,pH of urine,nitrite
- Renal Function Test
- Liver Function Test
- ECG(diabetics can come w MI causing the DKA)
- Cultures when necessary
- Chest X-ray when indicated
Acute: Hypoglycemia DKA Hyperglycemic hyperosmolar non Ketotic state (HHS) Lactic acidosis
Chronic:
MICROVASCULAR •Diabetic Eye Disease •Diabetic Retinopathy •Cataract •External ocular palsies •Diabetic Nephropathy •Diabetic Neuropathy
MACROVASCULAR
•Stroke
•Myocardial Infarction
•Peripheral Vascular Disease
- diabetic foot
- infections
- skin and joints problems
Impotence
Postural hypotension
What is hypoglycemia
What is the alert value for hypoglycemia in diabetics
And what’s the value for hypo in not al people
State six risk factors for severe hypoglycemia
All episodes of an abnormally low plasma glucose concentrations (with or without symptoms) that expose the individual to harm
Alert Value - < 3.9mmol/L or 4
•Clinically important biochemical hypoglycaemia - < 3mmol/
Strict glycaemic control
•Impaired awareness of hypoglycaemia
•Age (very young and elderly)
•Long duration of diabetes
•Sleep
•C-peptide negativity (indicating complete insulin deficiency)
•History of previous severe hypoglycaemia
•Renal impairment(when sugar is going down and proteins are in their urine think of renal impairment. It’s not that the diabetes is cured)
•Genetic, e.g. angiotensin-converting enzyme (ACE) genotype
State the classes of symptoms of hypoglycemia And give the symptoms in each class Why don’t most type 2s show autonomic symptoms? Which people wont present w autonomic symptoms at all
Symptoms differ with age; children exhibit behavioural changes (such as naughtiness or irritability), while elderly people experience more prominent neurological symptoms (such as visual disturbance and ataxia true or false
Autonomic: •Sweating •Trembling •Pounding heart •Hunger •Anxiety
Neuroglycopaenic: •Confusion •Drowsiness •Speech difficulty •Inability to concentrate •Incoordination •Irritability, anger
Nonspecific:
•Nausea
•Tiredness
•Headache
Most type 2s don’t cuz of neuropathy and can jump straight to neuroglycopaenic symptoms
The elderly patients
Symptoms differ with age; children exhibit behavioural changes (such as naughtiness or irritability), while elderly people experience more prominent neurological symptoms (such as visual disturbance and ataxia so true
State six causes of hypoglycemia
Drugs for diabetes oral hypoglycemics and insulin will stay longer in the body if there’s renal impairment true or false
State four ways you can avoid hypoglycemia while traveling
Missed, delayed or inadequate meal
•Unexpected or unusual exercise
•Alcohol
•Errors in oral anti-diabetic agent(s) or insulin dose/schedule/administration
•Poorly designed insulin regimen, particularly if predisposing to nocturnal hyperinsulinaemia
•Lipohypertrophy at injection sites causing variable insulin absorption
•Gastroparesis due to autonomic neuropathy causing variable carbohydrate absorption
•Malabsorption, e.g. coeliac disease
•Unrecognised other endocrine disorders, e.g. Addison’s disease
•Factitious (deliberately induced)
•Breastfeeding
Carry a supply of fast-acting carbohydrate (non-perishable in suitable containers)
➢Screwtop plastic bottles or glucose drinks
➢Packets of powdered glucose (for use in hot, humid climates)
➢Confectionery (foil-wrapped in hot climates)
➢Companions should carry additional oral carbohydrate, and glucagon
➢Perform frequent blood glucose testing
➢Carry spare meter and/or visually read strips
➢Use fast-acting insulin analogues for long-distance air travel
How is mild and severe hypoglycemia managed
Mild or self treated
•Oral fast-acting carbohydrate (10-15 g) is taken as glucose drink or tablets or confectionery
•Should be followed with a snack containing complex carbohydrate
Severe,external help will be required :
- If patient is semiconscious or unconscious; parenteral treatment is required
- IV 75ml 20% dextrose = 15 g OR
- Give 0.2g/kg in children
- IM glucagon 1mg (0.5mg in children)
- If patient is conscious and able to swallow
- Give oral refined glucose as drink or sweets = 25 g OR
- Apply glucose gel or jam or honey to buccal mucosa
What is DKA
Under what circumstances will it occur
When can DKA occur in type 2s
It is the hallmark of Type 1 DIabetes(insulin deficiency)
Previously underdiagnosed DM
•Interruption of insulin therapy
•The stress of intercurrent illness
in situations of relative insulin deficiency. So in type 2 there’s a state of relative insulin deficiency where insulin receptors don’t respond to insulin anymore as the disease progresses making DKA likely to occur
What are the clincial manifestations of DKA (history and exam)
What are the five principles of DKA management
History •Failure to comply with insulin therapy •Generalised weakness •Rapid weight loss (newly diagnosed) •Symptoms of infection (fever, dysuria etc)
Examination •Signs of shock •Pulse: >100bpm or <60bpm •Systolic Bp<90 mmHg •GCS <12 •O2 saturation <92% •Look for infection
Fluid replacement Replacement of deficient insulin Replacement of electrolyte losses Restore acid base balance Look for underlying cause
How is DKA diagnosed
How will bicarbonate show if there’s DKA
What’s the most common precipitatant of DKA
When will urinary ketones be negative in DKA
H yperglycaemia
•Measure blood glucose
•Ketonaemia
•Test plasma with Ketostix (if available)
•Finger-prick sample for β-hydroxybutyrate
•Ketonuria
•Measure urine ketone levels where plasma ketone measurements are not available
•Acidosis: measure
•pH in arterial blood
•Bicarbonate in venous blood
Bicarbonate can be measured on RFT.
It’s high in alkalosis and low in acidosis so it’ll be low if there’s DKA
Common include infections,dehydration, infarction
They’ll be negative if the patient w DKA presents early so in this case repeat again after six hours to check if ketones are in the urine
What do you do immediately if there’s DKA
1.Asses
2.Send bloods to laboratory
3.Set up i.v infusion
•Blood glucose
•Measure baseline and hourly initially
•Aim for fall of 3-6mmol/L (55-110mg/dL) per hour
•Urea and electrolytes
•Perform at baseline and hourly until 6 hours, then at 12 hours and 24 hours
•Potassium: add when K+ <3.5 mmol/L. Give 20 mmol/h in infusion. 10mmol/h when K+ = 3.5-5 mmol/L
•Full blood count
•Blood gases: at 0, 2 hours, 6 hours
•Creatinine: at 0, 6, 12, 24 hours
•Bicarbonate: at 0, 1, 2, 3, 6, 12, 24 hours
What is done in phase 1 management of DKA
Admit to HDU(high dependency unit) •Insulin •Soluble insulin i.v 0.1 u/kg/h by infusion •Fluid and Electrolyte Replacement: •IV 0.9% NaCl with 20 mmol KCl/L •1 L in 30min, then •1 L in 1 h •1 L in 2 h •1 L in 4 h •1 L in 8 h •Adjust KCl concentration depending on results of regular blood K+ measurement
If Blood pressure below 80 mmHg, give 500 mL 0.9% NaCl over 15mins; if no response, give plasma expander
•pH below 7.0 give 500 mL of NaCl 1.26% plus 10mmol KCl. Repeat if necessary to bring pH up to 7.0
What is done in phase 2 management and phase three
I’m phase three you’re finding the cause of the DKA
True or false
How can you differentiate DKA and HHS
Insulin and Glucose
•When blood glucose falls to 10-12 mmol/L, change infusion fluid to 1 L 5% glucose plus 20 mmol KCL 6-hourly.
•Continue insulin with dose adjusted according to hourly blood glucose test results (e.g. i.v. 3 U/h glucose 15 mmol/L; 2 U/h when glucose 10 mmol/L
Once stable and able to eat and drink normally, transfer patient to four times daily subcutaneous insulin regimen (based on previous 24 hours’ insulin consumption and trend consumption).
•Other semi-urgent procedures
•Blood and urine culture
•Cardiac enzymes
•Chest X-ray
•ECG
•Monitor if electrolyte problems or severe DKA
•Catheterisation if no urine passed after 3 hours of hydration
Give antibiotics if there’s infection
True
Using Urine dipstick
Bicarbonate levels can be used to differentiate the two
