L15: Diabetic Emergencies Flashcards
What are the 2 main diabetic emergencies
Diabetic ketoacidosis
Hyperosmolar hyperglycaemic state
What are these diabetic emergencies as a result of
Insulin deficiency
Why do the symptoms develop in diabetic emergency
- Hepatic glucose production is not supressed so glucose increases
- There is reduced uptake of glucose
- This increases glucose and exceeds the urinary threshold- this leads to dehydration and osmotic diuresis and secondary loss of body electrolytes
- There is also increased breakdwon od fat and protein (lipolysis) in the absence of inuslin which leads to increased ketones produced
- Ketones lead to acidosis
What are the symptoms of hyperglycaemia
Polyuria Thirst Thrush Visual chnages Coma Collapse Death
If there is acidosis what can the patient present with
Vasodilation
Dyspnoea
What is the triad for DKA
Hyperglycaemia
Ketone bodies
Metabolic acidosis
What are the causes of DKA
Insulin deficiency
Stress e.g infection
What is the pathophysiology of DKA
- 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
What is DKA an emergency
It can lead to: Hypovolaemic shock MI Cerebral oedema and pulmonary oedema Infection Adult respiratory distress syndrome
What are some factors that can increase the risk of DKA
Infection
Missing treatment
Stress
Pregnancy
How do we prevent DKA
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
What are the 3 criterias that need to be met for DKA to be diagnosed
- Hyperglycaemia: finger prick test more than 11 or need to be known for diabetes
- Ketones: more than 3 or ketoneuria (ketones in urine) that should be 3+ standard urine dipstick
- Acidosis: ph needs to be less than 7.3 or bicarbonate less than 15mmol/l
What is the management of DKA
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
What is resolution of DKA defined as
Blood ketones less than 0.3mmol or ph above 7.3
What is the pathophysiology of hyperosmolar hyperglycaemic state
- Hyperglycaemia causes osmotic diuresis (excess water and electroyle losses) which leads to hyperosmolarity
- Hyperosmolarity leads to an osmotic shift in water, so water leaves the cells and goes int the intravascular compartment which leads to intracellular dehydration
- Patient does not become ketoacidotic
What is the criteria for hyperosmolar hyperglycaemic state
Hypovolaemia
Hyperglycaemia
High osmolality
What is the presenation of hhs
Slower onsent
Hyperglycaemia features
Dehydrtion
Lack of symptoms of acidosis
What investgations can be carried out in HSS
Glucose: greater than 30
Not acidotic or ketodotic
Hyperosmolar: serum osmolality should be greater than 320
What is the managemnt of hhs
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
What is hypglycaemia
Blood glucose level low enough to cause whipples triad:
- Low plasma glucose
- Symptoms
- Resolution of these symptoms with correction of hypoglycaemia
Biochemically: less than 4mmol in patients with diabetes
What are the symptoms of hypoglycaemia
Autonimic symptoms: sweating, pallor,tachycardia, tremor, tingling and hunger
Nuerological: confusion, odd behaviour, drowsiness, slutting, dizzines and headache
What ar the causes of hypoglycaemia
Too musch insulin Insufienct food intake Exercise Alcohol Strict glycaemic control
What is the treatment of hypoglycaemia depend on
If the patient is consious or unconscious
If concious- get them too eat
If unconcious- iv
What is the management of a concious patient
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
