Endocrine - Level 1

Question 1

Definition of hypoglycaemia?

Answer 1

• Defined as blood glucose ≤4mmol/L
• In hospital, any blood sugar <4mmol/L should be treated promptly
• Can mimic any neurological presentation

Question 2

Prevalence of hypoglycaemia?

Answer 2

• 30% prevalence in T1DM

Question 3

Risk factors of hypoglycaemia?

Answer 3

o	Strict glycaemic control
o	Impaired awareness of hypoglycaemia
o	Increased duration of diabetes
o	Alcohol
o	Injection into lipohypertrophic sites

Question 4

Causes - diabetic of hypoglycaemia?

Answer 4

 Insulin or sulphonylurea with increased activity, missed meal, overdose

Question 5

Causes - non-diabetic of hypoglycaemia?

Answer 5

 Exogenous drugs (insulin, sulphonylureas, alcohol, ACEi, BB)
 Pituitary insufficiency
 Liver Failure
 Addison’s disease
 Insulinoma
 Non-pancreatic neoplasms (fibrosarcoma)

Question 6

Symptoms of hypoglycaemia?

Answer 6

• Rapid onset
• Preceded by odd behaviour
• Autonomic
  o Sweating, tachycardia, anxiety, hunger, tremor, palpitations
• Neuroglycopenic
  o Confusion, drowsiness, visual trouble, seizures and coma

Question 7

Investigations of hypoglycaemia?

Answer 7

• BMG (if <3, take lab glucose)

- Bloods – glucose, LFTs, TFTs, HbA1c

Question 8

Diagnosis of hypoglycaemia - triad?

Answer 8

• Diagnosis (Whipple’s triad)
  o Plasma hypoglycaemia
  o Symptoms of low blood sugar
  o Resolution with correction of hypoglycaemia

Question 9

Management of hypoglycaemia - conscious or mild hypoglycaemia?

Answer 9

 10-20g of fast-acting oral carbohydrates (Lucozade, sugar lumps, GlucoGel, Dextrogel)
• Repeat BMG after 15 mins, repeat step up to 1-3 times if needed

 After treatment, give longer-acting carbohydrate (sandwich, fruit, milk, biscuits or next meal)

Question 10

Management of hypoglycaemia - unconscious or severe hypoglycaemia?

Answer 10

If IV Access not available rapidly:
Glucagon 1mg, SC/IM (not suitable in alcohol, sulfonylureas or liver failure)
• If not effective in 10 minutes, give IV glucose

If IV access:
IV glucose (e.g. 15g of 150ml 10% glucose over 15 minutes or 10g of Glucose 20% (50mls)) through large vein and large-gauge needle
•	Infusion can be given if prolonged 

 After treatment, give 20g longer-acting carbohydrate (sandwich, fruit, milk, biscuits or next meal)

Question 11

Management if prolonged hypoglycaemic coma?

Answer 11

o Usually >5 hours and caused by cerebral oedema
o IV mannitol and dexamethasone
o IV glucose

Question 12

When are ketones produced by body?

Answer 12

• Ketoacidosis is alternative metabolic pathway, normally used in starvation states
• Produces acetone as by-product

Question 13

Pathology of DKA?

Answer 13

o Excessive glucose, but due to lack of insulin, cannot be up taken into cells to be metabolised
o Causes osmotic diuresis, with Na and water loss
o Pushes body into starvation states where ketoacidosis is only mechanism of production – increased lipolysis
o Produces non-esterized fatty acids, oxidised in liver to ketones

Question 14

Risk factors of DKA?

Answer 14

o Infection
o Infarction
o Insufficient insulin
o Intercurrent illness

Question 15

Symptoms and signs of DKA?

Answer 15

o Dehydration – thirst, polydipsia, polyuria, decreased skin turgor, dry mouth, hypotension, tachycardia
o GI – nausea, vomiting, abdominal pain
o Hyperventilation – (resp compensation for metabolic acidosis) Deep rapid (Kussmaul breathing) and smell of acetone on breath
o Altered conscious state, focal neurological deficits

Question 16

When to get critical care review in DKA? PHOSSVGK

Answer 16

o	Pregnant
o	Heart Failure
o	Oliguria or Anuria
o	Sat <92% on air
o	Systolic BP <90mmHg after 2L of fluid
o	Venous bicarbonate <5mmol/L or pH<7.1
o	GCS<12
o	K<3.5 on admission

Question 17

Essential investigations when DKA suspected?

Answer 17

o FBC, U&E, glucose
o VBG for bicarbonate, K, pH
o Depending on clinical suspicion – ECG/CXR/MSU/blood cultures/pregnancy test

Question 18

Diagnosis of DKA?

Answer 18

o	Hyperglycaemia  (>11mmol/L)
o	Ketonaemia (>3mmol/L or ++ or above on strip marking scale)
o	Acidaemia (pH<7.3 or plasma bicarbonate <18)

Question 19

Initial management of DKA?

Answer 19

o ABCDE approach
 Secure airway if GCS low
 2 large-bore cannulas

o If BP <90 – 500ml Bolus 0.9% saline (max 2L, then call critical care)

Question 20

Fluid management of DKA?

Answer 20

If BP>90mmHg or responds to 1st bolus:

 1L 0.9% Saline in 1st hour, 1L over 2 hours, 1L over 2 hours, 1L over 4 hours, 1L over 4 hours, 1L over 6 hours

Question 21

Insulin management of DKA?

Answer 21

Insulin – fixed rate
 IVI 50U actrarapid (soluable insulin) to 50mL 0.9% saline – 0.1u/kg/hr (1 unit/ml)
• Can increase to 1u/h
 Continue long-acting insulin therapies

Call Diabetes specialist team

Question 22

Subsequent management of DKA - potassium replacement?

Answer 22

o Potassium Replacement (40mmol/L KCl added)
 Don’t add K to 1st bag unless <3.5
 Monitor UO hourly, infuse at 20mmol/hour
 Check U&E hourly initially and replace as required
• >5.5 None
• 3.5-5.5mmol/L – 40mmol KCl/litre of IV fluid
• <3.5mmol/L – senior review (>40 may be necessary)
 Continuous ECG monitoring

Question 23

Subsequent management of DKA - further management after potassium replacement?

Answer 23

o Catheter and NG tube (if drowsy)
o LMWH Anticoagulation
o When glucose <14mmol/L
 10% glucose at 125mL/h to prevent hypoglycaemia alongside sodium chloride

Question 24

Monitoring in DKA?

Answer 24

o Vital signs hourly for 1st 4-6 hours and frequently thereafter
o Capillary glucose, ketones & VBG hourly
o U&Es every 6 hours

Question 25

Targets of treatment in DKA?

Answer 25

o Blood glucose fall of >3mmol/L/hour until 14mmol/L (if not falling, increased insulin to 1U/hr)

o Venous bicarbonate rise >3mmol/L/hour until 15mmol/L

o Capillary ketones fall >0.5mmol/L/hour until <0.6mmol/L

Question 26

Management after recovery in DKA?

Answer 26

o Transfer to SC insulin when patient well, able to eat and drink and venous pH >7.3 or blood ketones <0.6mmol/L
o Give SC fast-acting insulin and a meal and stop infusion

Question 27

Complications in DKA?

Answer 27

o	Cerebral oedema
	Headache, agitation, fall in heart rate, increased blood pressure
o	Aspiration pneumonia
o	Hypokalaemia
o	Hypomagnesaemia
o	Hypophosphatemia
o	VTE

Question 28

Definition of impaired glucose tolerance?

Answer 28

FPG <7 and 75g OGTT 2h 7.8-11.0

Question 29

Definition of impaired fasting glucose?

Answer 29

FPG 6.0-7.0