L15: Diabetic Emergencies

Question 1

What are the 2 main diabetic emergencies

Answer 1

Diabetic ketoacidosis

Hyperosmolar hyperglycaemic state

Question 2

What are these diabetic emergencies as a result of

Answer 2

Insulin deficiency

Question 3

Why do the symptoms develop in diabetic emergency

Answer 3

1. Hepatic glucose production is not supressed so glucose increases
2. There is reduced uptake of glucose
3. This increases glucose and exceeds the urinary threshold- this leads to dehydration and osmotic diuresis and secondary loss of body electrolytes
4. There is also increased breakdwon od fat and protein (lipolysis) in the absence of inuslin which leads to increased ketones produced
5. Ketones lead to acidosis

Question 4

What are the symptoms of hyperglycaemia

Answer 4

Polyuria
Thirst
Thrush
Visual chnages
Coma
Collapse
Death

Question 5

If there is acidosis what can the patient present with

Answer 5

Vasodilation

Dyspnoea

Question 6

What is the triad for DKA

Answer 6

Hyperglycaemia
Ketone bodies
Metabolic acidosis

Question 7

What are the causes of DKA

Answer 7

Insulin deficiency

Stress e.g infection

Question 8

What is the pathophysiology of DKA

Answer 8

1. Stress causes increased glucose production from liver

2. Lipolysis (breakdown of fat and protein) in the absence of protein causes ketone production that leads to acidosis

Question 9

What is DKA an emergency

Answer 9

It can lead to:
Hypovolaemic shock
MI
Cerebral oedema and pulmonary oedema
Infection
Adult respiratory distress syndrome

Question 10

What are some factors that can increase the risk of DKA

Answer 10

Infection
Missing treatment
Stress
Pregnancy

Question 11

How do we prevent DKA

Answer 11

Recognise early symptoms
Sick day rule: take more insulin when you are ill
Never miss doses of insulin if not even eating
Correcting high blood glucose levels with quick acting insulin

Question 12

What are the 3 criterias that need to be met for DKA to be diagnosed

Answer 12

1. Hyperglycaemia: finger prick test more than 11 or need to be known for diabetes
2. Ketones: more than 3 or ketoneuria (ketones in urine) that should be 3+ standard urine dipstick
3. Acidosis: ph needs to be less than 7.3 or bicarbonate less than 15mmol/l

Question 13

What is the management of DKA

Answer 13

Fluid management: to correct hypertension and restore circulatory volume and help clear ketones, counteract dehydration and electrolyte imbalance.

Insulin: to supress ketogenesis. Given at a fixed rate intravenously

Avoid hypoglycaemia from occuring: as ketoacidosis corrected from the blood glucose can fall quickly. When glycose falls to less than 14 give 10% glucose infusion.

Pottassium:
To counteract the fall of potassium when insulin is given

Thromboprophylaxis: to prevent thrombosis

Antibiotics: for infeciton

Question 14

What is resolution of DKA defined as

Answer 14

Blood ketones less than 0.3mmol or ph above 7.3

Question 15

What is the pathophysiology of hyperosmolar hyperglycaemic state

Answer 15

1. Hyperglycaemia causes osmotic diuresis (excess water and electroyle losses) which leads to hyperosmolarity
2. Hyperosmolarity leads to an osmotic shift in water, so water leaves the cells and goes int the intravascular compartment which leads to intracellular dehydration
3. Patient does not become ketoacidotic

Question 16

What is the criteria for hyperosmolar hyperglycaemic state

Answer 16

Hypovolaemia
Hyperglycaemia
High osmolality

Question 17

What is the presenation of hhs

Answer 17

Slower onsent
Hyperglycaemia features
Dehydrtion
Lack of symptoms of acidosis

Question 18

What investgations can be carried out in HSS

Answer 18

Glucose: greater than 30
Not acidotic or ketodotic
Hyperosmolar: serum osmolality should be greater than 320

Question 19

What is the managemnt of hhs

Answer 19

Fluid replacement: patients are dehydrated therefore need saline

Insulin- only if glucose is not decreasing and patient is has significant ketonaemia

Pottasium replacement

Thrombophyaxis

Foot protections from uclers

Question 20

What is hypglycaemia

Answer 20

Blood glucose level low enough to cause whipples triad:

1. Low plasma glucose
2. Symptoms
3. Resolution of these symptoms with correction of hypoglycaemia

Biochemically: less than 4mmol in patients with diabetes

Question 21

What are the symptoms of hypoglycaemia

Answer 21

Autonimic symptoms: sweating, pallor,tachycardia, tremor, tingling and hunger
Nuerological: confusion, odd behaviour, drowsiness, slutting, dizzines and headache

Question 22

What ar the causes of hypoglycaemia

Answer 22

Too musch insulin
Insufienct food intake
Exercise
Alcohol
Strict glycaemic control

Question 23

What is the treatment of hypoglycaemia depend on

Answer 23

If the patient is consious or unconscious
If concious- get them too eat
If unconcious- iv

Question 24

What is the management of a concious patient

Answer 24

Give them rapid acting carbohydrate e.g smooth oragnge juice
Check blood glucose level ater 10 mins, if less than 4 then repeat
Consider im glucagon
If still less than 4 give iv glucose
Once recovered and glucose is more than 4 give long acting carbohydrate

Question 25

What is the management of a unconscious patient

Answer 25

ABCDE
Give iv glucose
Im glucagon
Recheck blood glucose levels if less than 4 then repeat iv glucose
Once recovered and bgl is more than 4 then give long acting carbohydrate eg biscuit