Endo Emergencies Flashcards
What are the three things needed for rapid Dx of DKA
D - BM >11
K - Ketones >3
A - acidosis ph<7.3
What are investigations necessary for DKA
Capillary ketones, glucose Assess damage (BLOODS: CBG, lab glucose, ketones, FBC, U&E, BC, WCC, CRP -- ABG) ECG Consider CXR, urine dip Find cause
What can trigger a DKA
V - MI Infection Trauma AI Metabilic - insulin missed, alcohol Inflammation - pancrewattis Neoplastic Drugs: insluin missed
Where may you have to transfer a DKA patient if severe
ITU /HDU
How do you manage DKA
Fluids Insulin Potassium Dextrose VTE prophylaxis (as dehydratred)
How much fluid do you give for DKA
500ml bolus over 15mins if SBP <90»_space; then 1L/HOUR
if SBP normal: start giving 1L/h immediately NaCò
How much insulin do you give for DKA
Add 50U of insulin to 50ml NaCl
infuse. at rate of 0.1U/kg/hr
Fixed rate IV insulin infusion
+ patient’s normal long acting SC insulin
How muck K+ do you give in DKA
Run 40mmol KCl in NaCl even if K+ is normal
(not in first bag through - only when K+ between 3.5 and 5.5)
This is because insulin can cause hypokalaemia
How much dextrose do you give in DKA and when
10% dextrose when BM<14, 100ml/h
What are common complications of DKA
Cerebral oedema
aspiration pneumonia
VTE
electrolyte imbalance
How does insulin cause hypokalaemia
it drives potassium into skeletal and hepatic cells
What is HHS
Hyperglycaemic hyperosmolar state
What kinds of patients does HHS occur in, and what are RF
Patients with T2DM
Usually if non-adherent to medications, infection, steroids…
What are sx of HHS
longer history than DKA (1 week) polyuria polydipsia decreased consciousness severe dehydration, volume depletion
How do you manage HHS
LMWH (high VTE risk)
Start IV fluids - 0.9% 1L NaCl over 2h
Start fixed rate insulin infusion 0.05U/kg/h only if glucose stops falling or if ketonuria 2+
THEN:
Slow rehydration over 48 hours - at half the rate of DKA fluids
Replace K+ when UO increases
What investigations must you get in a patient with suspected poisoning
ALL UNCONSCIOUS patients: glucose, paracetamol, salicylate levels
FBC, U&E, LFT, INR, ABG, ECG
How do you reverse benzo
Flumazenil
How do you reverse opiate
naxolone
how to you reverse paracetamol
N-acetylcysteine
How do you reverse. aspirin
sodium bicarb
How do you assess Burn Size
Rule of 9 Rule (“Lung and Browder”)
The palm is 1% of body area
Why is it important to estimate burn size
So you can estimate inflamm response and fluid shift > it may require fluid resus
> 10-15% TBSA will require fluid resus
Why is it important to assess thickness. of burn?
It influences healing time and scarring
What are the degrees of burns and can you describe them
1st degree: mild erythema
2nd degree: painful erythema
3rd degree: do not blister, no sensation, look leathery/brown/black
How do you manage burns patient
- fluid resus using Parkland’s formula – give crystalloid
2. Dressing
What is the Parkland formula for fluid resus
4ml x weight (kg) x % burn
What is hypothermia
Core rectal temperature <35 degrees
what are. investigations you need to do for hypothermia
- axillary / oral temp»_space; is less than 36.5, measure PR probe / infra-red ear. thermometer
- Full bloods
- ECG
What do you see on ECG in hypothermia
Bradyarrhythmia Osborne waves (J waves) Prolonged PR, QRS, QT interval Shivering artefact Ventricular ectopics Cardiac arrest (VT, VF, Asystole)
How do you manage hypothermia
A>E (do not expose to cold, start warm humidified oxygen, remove wet clothes)
Slowly rewarm at 0.5 deg /h, via blanket and warm IV infusion
Cardiac monitoring
What. are symptoms of CO poisoning.
headache N&V Vertigo Confusion Subjective weakness Pink skin. and mucosa, hyperpyrexia, arrythmia
What investigatons fo you need to do for CO poinsoning
Pulse oxymetry (will be falsely high) > do ABG/VBG High carboxyhaemoglobin levels
How. do. you manage CO poisoning
100% O2 via NRB for min 6h> target is 100% SpO2
What occurs in HHS
trigger (MI, infection etc) > lower insulin production > hyperglycaemia > glycosuria (osmotic diuresis) > loss or water and electrolyes > dehydration, low fluid intake > HYPEROSMOLARITY + impaired renal function (AKI)
What condition commonly occurs following HHS
AKI
How do you diagnose someone with HHS
HYPERGLYCAEMIC: Glu > 30
HYPEROSMOLAR: Osmolarity >320
How do you work out osmolarity
2 (Na + K) + urea + glucose
How do you manage hypoglyacaemi
DEPENDING ON CONSCIOUS STATE:
- conscious, orientated, able to swallow: carbohydrate snack
- conscious but uncooperative: buccal glucose e.g. glucogel
- unconscious: glucose IVI 20% 100ml/10mins or IM glucagon
what is a myxoedema coma
Severe hypothyroidism, due to culmination of severe longwithstanding hypothyroidism
What are precipitants of myxoedema coma
MI, stroke
infection
trauma
What are signs of myxoedema coma
ALL ORGANS SLOW DOWN
- bradycardia a
- deterioration in mental status (seizures, psychosis)
- hypthermia
- hyporeflexia
How do you investigate myxoedema com
TFT FBC U&E cortisol glucose ABG
How do you manage myxoedema coma
IV T3 (up to 20mcg/12h)
IV hydrocortisone
consider warming blanket, fluid, abx if suspecting antibiotics
What causes a thyrotoxic storm
Untreated / undertreated hyperthyroidism + precipitant
Same precipitants as myxoedema coma:
MI, stroke
infection
trauma
What are sx of thyrotoxi. storm
EXTREME HYPERTHYROID fever agitation confusion coma tachycardia AF diarrhoea and vomiting
How do you manage thyrotoxic storm
IV propanolol 60mg QDS > carbimazoole (inhibits TPO) > hydrocortisonee or dexamethasone
What is an addisonian crisis
Body cannot produce sufficient cortisol and aldosterone (usually precipitated by trigger in known addison’t patient) > SHOCK AND HYPOGLYCAEMIA
What are symptoms of addisonian crisis
SHOCK AND HYPO
How do you manage addisonian crisis
IM hydrocortisone 100mg STAT
IV fluid bolus
what do you need to check hourly in DKA
capillary blood glucose and ketones
what do you need to check every 2h (or as required) in DKA
VBG
what other interventions should you consider in DKA
inserting a CATHETER if they haven’t passed urine within first hour
NG tube if vomiting / drowsy
LMWH for ALL
when do you continue fixed rate insulin until
until pt stable: pH>7.3, ketones <0.6, bicarb >15
What do you do once patient stable
Give SC insulin infusion
Wait 30 mins, then stop addtional insulin
what is the max rate of potassium you can give
- per hour
- per bag
Max potassium per hour: 20mmol
max potassium per bag: 40mmol
What do you do if when attempting to treat paracetamol overdose they get a rash?
NAC often gives you a rash
STOP it and RESTART at a lower rate
How do you treat paracetamool overdose if presenting <1h
activated charcoal
then check paracetamol levelss 4 hours after ingestion
NAC if indicated
what do you do if paracetamol overdose presents >1h post injection
check paracetamol levels 4h after ingestion
then give NAC if indiixated
sx of salicylate (Aspirin) overdose
tintinnus, hyperventilation, vertigo
vomiting, sweating, dehydration
in DKA patient, which of their own insulin do you keep giving and which do you stop?
Keep giving their SC LONG ACTING insulin
STOP their SHORT acting insulin
