Hyperglycemia Emergencies Flashcards
How long is onset of DKA?
Rapid onset. Less than 24 hours.
How do you diagnose DKA?
No definitive diagnosis. Based on symptoms. Kussmaul-Kien respiration. Ie: rapid and deep. Acetone breath Hyperglycemia ECFV contraction Dehydration, hypotension. N,V abdominal pain. Impaired consciousness possible.
Findings: increased glucose. Increased anion gap. Increased serum and urine ketones or B-OHB >1
Decreased PH and bicarbonate.
What’s the clinical presentation of HHS
Hyperosmolar Hyperglycemic State.
Present similar to DKA BUT
NOT high in ketones.
TYPICALLY DEHYDRATED
Mental Status changed due to serum osmolality.
Seizures and coma more likely.
Not uncommon to have BG levels >50.
more Likely to be obese or elderly type2. Sometimes on diuretics.
Risk factors for DKA
Note: DKA much more prominent than HHS
Infection (most common cause. 30-40% of cases) Insulin omission! Insulin pump therapy New diagnosis of diabetes MI stroke Trauma, abdominal crisis Cocaine use Atypical antipsychotics Thyrotoxicosis
Risk factors for HHS
Infection (most common. 40-60% of cases)
Post cardiac surgery
Certain drugs: diuretics, glucocorticoids, lithium, atypical antipsychotics.
** up to 20% of people had no hx of D
RECOMMENDED Treatment protocol for DKA
1-Fluid resuscitation with NaCl
2- treat hypokalemia
3-Administration of insulin to manage acidosis! (NOT to normalize glucose!!) 0.1 unit per kg UNTIL anion gap normalizes. Once PG falls to 14 add dextrose to the insulin.
4- avoidance of rapidly falling serum osmolality
5- Search for precipitating factors.
IN THAT ORDER!! Ie: correct K before giving insulin!!
Recommended management of HHS
1-Fluid resuscitation.
2- Avoid hypokalemia
3- avoidance of rapidly falling serum osmolality
4-Search for precipitating factors
5-Possibly insulin administration to reduce hyperglycemia. (Not for acidosis as generally there isn’t any(
When should point of care beta hydroxy butyrate testing be done?
In hospital for any type 1 with BG > 14. If if BETA H B is greater than 1.5mmol/l then further testing warranted.
As part of sick day management. Proven to reduce emergency room visits and hospitalizations in young people.
When does a normal blood glucose NOT rule out DKA?
Pregnancy
Patient on an SGLT2
Explain pathway for DKA and HHS.
Insulin deficiency due to lack of (type 1) or reduction of endogenous or insulin resistance leads to hyperglycemia.
ALSO if type 2, see high levels of counter regulatory hormones (glucagon, cortisol, GH, catecholamines) contributing to high glucose levels through suppressing insulin release and causing glycogenolysis, gluconeogenesis and lypolysis (this is where the ketone bodies come from. Breakdown of FFA).
Body tries to dump extra glucose into urine and takes fluid and electrolytes with it.
Results in ECFV depletion, and hyperosmolality (signs in HHS).
Hypovolemia, dehydration, decreased GFR. Potassium is shifted out of cells and ketoacidosis occurs. DKA. Ie: high levels of FFA converted to ketone bodies (beta-hydroxybutyrate and acetoacetate). Leads to ketonemia and metabolic acidosis.
In DKA ketoacidosis is prominent
In HHS ketosis is rare, main features are ECFV depletion and hyperoamolarity
If an anion gap is greater than 12 would
You suspect DKA or rule it out?
Suspect
what should be done when blood ketones are greater than 3mmol/L?
go to Emerg immediately! need iv fluids and insulin
how often should blood ketone testing be done while sick?
every 4 hours (every 2-4hrs if on insulin pump).
What are the signs and symptoms of DKA
Hyperglycemia.
Polyuria, polydipsia, EVFV contraction
Acidosis.
Air hunger, N/V/abd pain, altered sensorium, Kussmaul respiration, acetone breath
The precipitating cause
Acidosis is present in DKA or HHS
DKA
Insulin is administered to correct this. If BG goes too low then dextrose can be added
