Hyperglycaemia (Adults)

Question 1

What are the clinical features of DKA/HHS

Answer 1

• dehydration
• tachypnoea
• polydipsia
• polyphagia
• polyuria
• Kussmaul’s breathing
• Hx diabetes

Question 2

When should we suspect DKA?

Answer 2

• in any patient with
  
  • pre existing history of diabetes
  • BGL >11mmol/L
  • AND
  • clinical features of DKA
    
    • confusion
    • signs of dehydration
    • Kussmaul’s breathing

Question 3

Patients with HHS are…

Answer 3

• Typically older
• Have higher BGL readings >30mmol/L
• usually do not present with clinical features of DKA (e.g. Kussmaul’s breathing)

Question 4

Do you need to identify if a patient is in DKA vs HHS?

Answer 4

No, there is no value in differentiating between hyperglycaemic crises in the prehospital setting. Adequate fluid replacement in patients with less than adequate perfusion should the aim of care in symptomatic patients

Question 5

Should patients be encouraged to self-administer additional doses of insulin prior to transport to hospital?

Answer 5

No

Question 6

Should DKA patients be intubated?

Answer 6

• preferably not, removing the patients ability to achieve compensatory respiratory alkalosis (i.e. Kussmaul’s respirations) can lead to poorer outcomes. ETT should be avoided unless the patient is severely obtunded

Question 7

Recite the Hyperglycaemia CPG (Adult)

Answer 7

Question 8

What is the pathophysiology of DKA?

Answer 8

• DKA is a life threatening complication usually seen in patients with T1DM.
• It is caused by an absolute insulin deficiency precipitating a number of physiological changes:
  
  • High BGL increases blood osmolarity drawing water out of cells resulting in cellular dehydration
  • High BGL in the kidney filtrate results in osmotic diuresis and polyuria leading to severe dehydration and hypovolaemia
  • Alternate fuel sources including fatty acids are used, producing organic acids known as ketones. Accumulation of these result in a metabolic acidosis
  • Dehydration leading to polydipsia
  • loss of potassium from the body

Question 9

What is DKA characterised by?

Answer 9

• Hyperglycaemia
• Ketosis
• Metabolic acidosis

Question 10

What is HHS?

Answer 10

Hyperosmolar Hypergluucaemia Syndrome (HHS). Is a life threatening complication of T2DM. That is characterised by Hyperglycaemia, Hyperosmolarity and severe dehydration

Question 11

What is the pathophysiology of HHS?

Answer 11

HHS is caused by a relative insulin deficiency, whereby there is sufficient insulin to limit ketone production thus preventing metabolic acidosis

Elevated levels of counter regulatory hormones (glucagon, catecholamines, cortisol and growth hormone) initiate HHS by stimulating hepatic glucose production through glycogenolysis and gluconeogenesis, leading to hyperglycaemia, intracellular water depletion and subsequent osmotic diuresis.

Question 12

What is Kussmaul’s breathing?

Answer 12

• It is a deep and laboured breathing pattern that is often associated with severe metabolic acidosis - hyperventilations occurs to reduce levels of CO2 in the blood - in metabolic acidosis, breathing is initially rapid and shallow. But as it worsens, the breathing pattern becomes deep, laboured and gasping. Which is referred to as Kussmauls breathing